Comprehensive Geriatric Assessment
in the 21st Century
Laurence Rubenstein MD MPH FACP Professor amp Chairman Reynolds Dept of Geriatric Medicine
University of Oklahoma College of Medicine
June 2015 -- St Gallen Switzerland
Outline
US Aging Demographics Geriatric Imperative
Comprehensive Geriatric Assessment (CGA)
history purposes benefits
Geriatric care programs services financing
Future needs directions
The Geriatric Imperativerdquo
Increasing Elderly
Population
Vast Unmet Healthcare
Needs
13 US pop 65+
What is Special About Older Persons
bullMultiple interacting chronic diseases common
bullAtypical disease presentation
bullMany causes for functional dependency
bullMany sources for pain amp discomfort
bullDiminished reserve capacity
bullSpecial pharmacological considerations
bullSlower communication longer history
Comprehensive Geriatric Assessment
bull ldquoThe New Technology of Geriatricsrdquo
--Epstein Ann Intern Med 1987
bull Definition ldquoA Multidimensional
interdisciplinary diagnostic process to
identify care needs plan care and improve
outcomes of frail older peoplerdquo
Geriatric Assessment Purposes
Improve diagnostic accuracy
Optimize medical treatment
Improve medical outcomes
Improve function amp quality of life
Optimize living location
Minimize unnecessary service use
Arrange long-term case management
Community Office Clinic
Home Visits
Hospital Special Care
Unit Consult Team
Nursing Home Special Beds
Admission Protocol
GERIATRIC ASSESSMENT WHERE
CGA The Hub of the Geriatric
Care System Rehab or Subacute
Unit
Day Care
Home Care
Respite
Case Mgmt
Nursing Home
Hospital
OPD
Community
CGA
CGA Measurable Dimensions
bull Physical health ndash Traditional history physical exam lab data problem list ndash Disease-specific severity indicators ndash Prevention practices (eg exercise asa vaccination)
bull Functional status ndash ADL amp IADL scales ndash Other functional scales (eg mobility quality of life)
bull Psychological health ndash Cognitive amp affective function scales
bull Socio-environmental parameters ndash Social networks amp supports ndash Economic adequacy ndash Environmental safety amp needs
GERIATRIC ASSESSMENT WHY
Much unreported treatable disease
and disability
Premature nursing home placement
Neglected rehabilitation
Excessive drug useiatrogenesis
Assessment improves outcomes
Benefits of CGA Programs
Diagnosis
Function
Placement
Affect
Cognition
Medications
NH Use
Hospital Use
Costs
Mortality
Randomized Trial of a Hospital Geriatric Evaluation amp Management Unit
Ref Rubenstein et al N Engl J Med 1984 3111664-70
Mortality (24 vs 48 at 1 yr)
NH Use (27 vs 47)
Rehosps (35 vs 50)
Costs ($22K vs $28K yr)
ADL (42 vs 24 at 1 yr)
Morale (42 vs 24 )
The Sepulveda GEM Study
In-Home CGA amp Case Management RCT Copenhagen (Br Med J 1984 2891522-1524)
Program
(N=285)
Controls
(N=287)
196
7
219
4884
30
16
35
261
10
271
6442
60
10
23
P
3-Year Mortality
NH Admissions
Hospital Admissions
Hospital Bed Days
Emergency Dept Visits
Home Help Provision
Home Modifications
lt05
NS
lt01
lt01
lt05
lt05
lt05
Cost of program more than matched by savings
Hospital GEM Programs Published RCTs Reference TypeTarg Significant Impacts
surv fct NHhosp$
surv LOS$(12)
none
survcog drugs
dx(surv)
survfct ( hosp)
fct(surv) NH
affect
none
surv readm
fct NHhosp$
fct NH LOS lab ($)
$ LOS
$ re-adm hosp
satis (surv)
fct satis
fct NH
Rubenstein 84 CA
Collard 85 MA
Allen 86 NC
Hogan 87 Can
Gilchrist 88 UK
Hogan 90 Can
Applegate 90 TN
Fretwell 90 RI
Harris 91 Aus
Thomas 91 NC
Melin 92 Swe
Powers lsquo92 TN
Naughton lsquo94 IL
Naylor lsquo949 PANY
Reuben lsquo95 CA
Karppi lsquo95 Fin
Landefeld lsquo95 OH
Ward++
Ward0
Cons0
Cons+
Ward+
Cons+
Ward++
Cons0
Ward0
Cons0
Cons+fu0
Ward++
Cons++
Cons+fu0
Cons+
Ward+
Ward0
Outpatient GAPs Published RCTs Reference Typefu Significant Impacts
dxfct hosp
surv hosp$(NH)
surv(affect)
hosp$
none
(cog)
NHfalls
surv
(surv) NH(hosp)
survfct hosp
home-surv
fct process
fct NH
fct NH hosp $
surv fct satis
fctcog hosp $
Tullock 79 UK
Hendricksen 84 Den
Vetter 84 UK
Williams 87 NY
Sorensen 88 Den
Epstein 90 RI
Carpenter 90 UK
Vetter 92 UK
Hansen 92 Den
Pathy 92 UK
Hall lsquo94 Can
Fabacher lsquo94 CA
Stuck lsquo95 CA
Melin lsquo95 Swe
Engelhardt lsquo96 NY
Bernabei lsquo98 It
OPD ++
Home ++
Home ++
OPD 0
Home 0
OPD 0
Home ++
Home ++
Home ++
Home +
Home +
Home +
Home ++
Home ++
OPD +
Home ++
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Outline
US Aging Demographics Geriatric Imperative
Comprehensive Geriatric Assessment (CGA)
history purposes benefits
Geriatric care programs services financing
Future needs directions
The Geriatric Imperativerdquo
Increasing Elderly
Population
Vast Unmet Healthcare
Needs
13 US pop 65+
What is Special About Older Persons
bullMultiple interacting chronic diseases common
bullAtypical disease presentation
bullMany causes for functional dependency
bullMany sources for pain amp discomfort
bullDiminished reserve capacity
bullSpecial pharmacological considerations
bullSlower communication longer history
Comprehensive Geriatric Assessment
bull ldquoThe New Technology of Geriatricsrdquo
--Epstein Ann Intern Med 1987
bull Definition ldquoA Multidimensional
interdisciplinary diagnostic process to
identify care needs plan care and improve
outcomes of frail older peoplerdquo
Geriatric Assessment Purposes
Improve diagnostic accuracy
Optimize medical treatment
Improve medical outcomes
Improve function amp quality of life
Optimize living location
Minimize unnecessary service use
Arrange long-term case management
Community Office Clinic
Home Visits
Hospital Special Care
Unit Consult Team
Nursing Home Special Beds
Admission Protocol
GERIATRIC ASSESSMENT WHERE
CGA The Hub of the Geriatric
Care System Rehab or Subacute
Unit
Day Care
Home Care
Respite
Case Mgmt
Nursing Home
Hospital
OPD
Community
CGA
CGA Measurable Dimensions
bull Physical health ndash Traditional history physical exam lab data problem list ndash Disease-specific severity indicators ndash Prevention practices (eg exercise asa vaccination)
bull Functional status ndash ADL amp IADL scales ndash Other functional scales (eg mobility quality of life)
bull Psychological health ndash Cognitive amp affective function scales
bull Socio-environmental parameters ndash Social networks amp supports ndash Economic adequacy ndash Environmental safety amp needs
GERIATRIC ASSESSMENT WHY
Much unreported treatable disease
and disability
Premature nursing home placement
Neglected rehabilitation
Excessive drug useiatrogenesis
Assessment improves outcomes
Benefits of CGA Programs
Diagnosis
Function
Placement
Affect
Cognition
Medications
NH Use
Hospital Use
Costs
Mortality
Randomized Trial of a Hospital Geriatric Evaluation amp Management Unit
Ref Rubenstein et al N Engl J Med 1984 3111664-70
Mortality (24 vs 48 at 1 yr)
NH Use (27 vs 47)
Rehosps (35 vs 50)
Costs ($22K vs $28K yr)
ADL (42 vs 24 at 1 yr)
Morale (42 vs 24 )
The Sepulveda GEM Study
In-Home CGA amp Case Management RCT Copenhagen (Br Med J 1984 2891522-1524)
Program
(N=285)
Controls
(N=287)
196
7
219
4884
30
16
35
261
10
271
6442
60
10
23
P
3-Year Mortality
NH Admissions
Hospital Admissions
Hospital Bed Days
Emergency Dept Visits
Home Help Provision
Home Modifications
lt05
NS
lt01
lt01
lt05
lt05
lt05
Cost of program more than matched by savings
Hospital GEM Programs Published RCTs Reference TypeTarg Significant Impacts
surv fct NHhosp$
surv LOS$(12)
none
survcog drugs
dx(surv)
survfct ( hosp)
fct(surv) NH
affect
none
surv readm
fct NHhosp$
fct NH LOS lab ($)
$ LOS
$ re-adm hosp
satis (surv)
fct satis
fct NH
Rubenstein 84 CA
Collard 85 MA
Allen 86 NC
Hogan 87 Can
Gilchrist 88 UK
Hogan 90 Can
Applegate 90 TN
Fretwell 90 RI
Harris 91 Aus
Thomas 91 NC
Melin 92 Swe
Powers lsquo92 TN
Naughton lsquo94 IL
Naylor lsquo949 PANY
Reuben lsquo95 CA
Karppi lsquo95 Fin
Landefeld lsquo95 OH
Ward++
Ward0
Cons0
Cons+
Ward+
Cons+
Ward++
Cons0
Ward0
Cons0
Cons+fu0
Ward++
Cons++
Cons+fu0
Cons+
Ward+
Ward0
Outpatient GAPs Published RCTs Reference Typefu Significant Impacts
dxfct hosp
surv hosp$(NH)
surv(affect)
hosp$
none
(cog)
NHfalls
surv
(surv) NH(hosp)
survfct hosp
home-surv
fct process
fct NH
fct NH hosp $
surv fct satis
fctcog hosp $
Tullock 79 UK
Hendricksen 84 Den
Vetter 84 UK
Williams 87 NY
Sorensen 88 Den
Epstein 90 RI
Carpenter 90 UK
Vetter 92 UK
Hansen 92 Den
Pathy 92 UK
Hall lsquo94 Can
Fabacher lsquo94 CA
Stuck lsquo95 CA
Melin lsquo95 Swe
Engelhardt lsquo96 NY
Bernabei lsquo98 It
OPD ++
Home ++
Home ++
OPD 0
Home 0
OPD 0
Home ++
Home ++
Home ++
Home +
Home +
Home +
Home ++
Home ++
OPD +
Home ++
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
The Geriatric Imperativerdquo
Increasing Elderly
Population
Vast Unmet Healthcare
Needs
13 US pop 65+
What is Special About Older Persons
bullMultiple interacting chronic diseases common
bullAtypical disease presentation
bullMany causes for functional dependency
bullMany sources for pain amp discomfort
bullDiminished reserve capacity
bullSpecial pharmacological considerations
bullSlower communication longer history
Comprehensive Geriatric Assessment
bull ldquoThe New Technology of Geriatricsrdquo
--Epstein Ann Intern Med 1987
bull Definition ldquoA Multidimensional
interdisciplinary diagnostic process to
identify care needs plan care and improve
outcomes of frail older peoplerdquo
Geriatric Assessment Purposes
Improve diagnostic accuracy
Optimize medical treatment
Improve medical outcomes
Improve function amp quality of life
Optimize living location
Minimize unnecessary service use
Arrange long-term case management
Community Office Clinic
Home Visits
Hospital Special Care
Unit Consult Team
Nursing Home Special Beds
Admission Protocol
GERIATRIC ASSESSMENT WHERE
CGA The Hub of the Geriatric
Care System Rehab or Subacute
Unit
Day Care
Home Care
Respite
Case Mgmt
Nursing Home
Hospital
OPD
Community
CGA
CGA Measurable Dimensions
bull Physical health ndash Traditional history physical exam lab data problem list ndash Disease-specific severity indicators ndash Prevention practices (eg exercise asa vaccination)
bull Functional status ndash ADL amp IADL scales ndash Other functional scales (eg mobility quality of life)
bull Psychological health ndash Cognitive amp affective function scales
bull Socio-environmental parameters ndash Social networks amp supports ndash Economic adequacy ndash Environmental safety amp needs
GERIATRIC ASSESSMENT WHY
Much unreported treatable disease
and disability
Premature nursing home placement
Neglected rehabilitation
Excessive drug useiatrogenesis
Assessment improves outcomes
Benefits of CGA Programs
Diagnosis
Function
Placement
Affect
Cognition
Medications
NH Use
Hospital Use
Costs
Mortality
Randomized Trial of a Hospital Geriatric Evaluation amp Management Unit
Ref Rubenstein et al N Engl J Med 1984 3111664-70
Mortality (24 vs 48 at 1 yr)
NH Use (27 vs 47)
Rehosps (35 vs 50)
Costs ($22K vs $28K yr)
ADL (42 vs 24 at 1 yr)
Morale (42 vs 24 )
The Sepulveda GEM Study
In-Home CGA amp Case Management RCT Copenhagen (Br Med J 1984 2891522-1524)
Program
(N=285)
Controls
(N=287)
196
7
219
4884
30
16
35
261
10
271
6442
60
10
23
P
3-Year Mortality
NH Admissions
Hospital Admissions
Hospital Bed Days
Emergency Dept Visits
Home Help Provision
Home Modifications
lt05
NS
lt01
lt01
lt05
lt05
lt05
Cost of program more than matched by savings
Hospital GEM Programs Published RCTs Reference TypeTarg Significant Impacts
surv fct NHhosp$
surv LOS$(12)
none
survcog drugs
dx(surv)
survfct ( hosp)
fct(surv) NH
affect
none
surv readm
fct NHhosp$
fct NH LOS lab ($)
$ LOS
$ re-adm hosp
satis (surv)
fct satis
fct NH
Rubenstein 84 CA
Collard 85 MA
Allen 86 NC
Hogan 87 Can
Gilchrist 88 UK
Hogan 90 Can
Applegate 90 TN
Fretwell 90 RI
Harris 91 Aus
Thomas 91 NC
Melin 92 Swe
Powers lsquo92 TN
Naughton lsquo94 IL
Naylor lsquo949 PANY
Reuben lsquo95 CA
Karppi lsquo95 Fin
Landefeld lsquo95 OH
Ward++
Ward0
Cons0
Cons+
Ward+
Cons+
Ward++
Cons0
Ward0
Cons0
Cons+fu0
Ward++
Cons++
Cons+fu0
Cons+
Ward+
Ward0
Outpatient GAPs Published RCTs Reference Typefu Significant Impacts
dxfct hosp
surv hosp$(NH)
surv(affect)
hosp$
none
(cog)
NHfalls
surv
(surv) NH(hosp)
survfct hosp
home-surv
fct process
fct NH
fct NH hosp $
surv fct satis
fctcog hosp $
Tullock 79 UK
Hendricksen 84 Den
Vetter 84 UK
Williams 87 NY
Sorensen 88 Den
Epstein 90 RI
Carpenter 90 UK
Vetter 92 UK
Hansen 92 Den
Pathy 92 UK
Hall lsquo94 Can
Fabacher lsquo94 CA
Stuck lsquo95 CA
Melin lsquo95 Swe
Engelhardt lsquo96 NY
Bernabei lsquo98 It
OPD ++
Home ++
Home ++
OPD 0
Home 0
OPD 0
Home ++
Home ++
Home ++
Home +
Home +
Home +
Home ++
Home ++
OPD +
Home ++
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
What is Special About Older Persons
bullMultiple interacting chronic diseases common
bullAtypical disease presentation
bullMany causes for functional dependency
bullMany sources for pain amp discomfort
bullDiminished reserve capacity
bullSpecial pharmacological considerations
bullSlower communication longer history
Comprehensive Geriatric Assessment
bull ldquoThe New Technology of Geriatricsrdquo
--Epstein Ann Intern Med 1987
bull Definition ldquoA Multidimensional
interdisciplinary diagnostic process to
identify care needs plan care and improve
outcomes of frail older peoplerdquo
Geriatric Assessment Purposes
Improve diagnostic accuracy
Optimize medical treatment
Improve medical outcomes
Improve function amp quality of life
Optimize living location
Minimize unnecessary service use
Arrange long-term case management
Community Office Clinic
Home Visits
Hospital Special Care
Unit Consult Team
Nursing Home Special Beds
Admission Protocol
GERIATRIC ASSESSMENT WHERE
CGA The Hub of the Geriatric
Care System Rehab or Subacute
Unit
Day Care
Home Care
Respite
Case Mgmt
Nursing Home
Hospital
OPD
Community
CGA
CGA Measurable Dimensions
bull Physical health ndash Traditional history physical exam lab data problem list ndash Disease-specific severity indicators ndash Prevention practices (eg exercise asa vaccination)
bull Functional status ndash ADL amp IADL scales ndash Other functional scales (eg mobility quality of life)
bull Psychological health ndash Cognitive amp affective function scales
bull Socio-environmental parameters ndash Social networks amp supports ndash Economic adequacy ndash Environmental safety amp needs
GERIATRIC ASSESSMENT WHY
Much unreported treatable disease
and disability
Premature nursing home placement
Neglected rehabilitation
Excessive drug useiatrogenesis
Assessment improves outcomes
Benefits of CGA Programs
Diagnosis
Function
Placement
Affect
Cognition
Medications
NH Use
Hospital Use
Costs
Mortality
Randomized Trial of a Hospital Geriatric Evaluation amp Management Unit
Ref Rubenstein et al N Engl J Med 1984 3111664-70
Mortality (24 vs 48 at 1 yr)
NH Use (27 vs 47)
Rehosps (35 vs 50)
Costs ($22K vs $28K yr)
ADL (42 vs 24 at 1 yr)
Morale (42 vs 24 )
The Sepulveda GEM Study
In-Home CGA amp Case Management RCT Copenhagen (Br Med J 1984 2891522-1524)
Program
(N=285)
Controls
(N=287)
196
7
219
4884
30
16
35
261
10
271
6442
60
10
23
P
3-Year Mortality
NH Admissions
Hospital Admissions
Hospital Bed Days
Emergency Dept Visits
Home Help Provision
Home Modifications
lt05
NS
lt01
lt01
lt05
lt05
lt05
Cost of program more than matched by savings
Hospital GEM Programs Published RCTs Reference TypeTarg Significant Impacts
surv fct NHhosp$
surv LOS$(12)
none
survcog drugs
dx(surv)
survfct ( hosp)
fct(surv) NH
affect
none
surv readm
fct NHhosp$
fct NH LOS lab ($)
$ LOS
$ re-adm hosp
satis (surv)
fct satis
fct NH
Rubenstein 84 CA
Collard 85 MA
Allen 86 NC
Hogan 87 Can
Gilchrist 88 UK
Hogan 90 Can
Applegate 90 TN
Fretwell 90 RI
Harris 91 Aus
Thomas 91 NC
Melin 92 Swe
Powers lsquo92 TN
Naughton lsquo94 IL
Naylor lsquo949 PANY
Reuben lsquo95 CA
Karppi lsquo95 Fin
Landefeld lsquo95 OH
Ward++
Ward0
Cons0
Cons+
Ward+
Cons+
Ward++
Cons0
Ward0
Cons0
Cons+fu0
Ward++
Cons++
Cons+fu0
Cons+
Ward+
Ward0
Outpatient GAPs Published RCTs Reference Typefu Significant Impacts
dxfct hosp
surv hosp$(NH)
surv(affect)
hosp$
none
(cog)
NHfalls
surv
(surv) NH(hosp)
survfct hosp
home-surv
fct process
fct NH
fct NH hosp $
surv fct satis
fctcog hosp $
Tullock 79 UK
Hendricksen 84 Den
Vetter 84 UK
Williams 87 NY
Sorensen 88 Den
Epstein 90 RI
Carpenter 90 UK
Vetter 92 UK
Hansen 92 Den
Pathy 92 UK
Hall lsquo94 Can
Fabacher lsquo94 CA
Stuck lsquo95 CA
Melin lsquo95 Swe
Engelhardt lsquo96 NY
Bernabei lsquo98 It
OPD ++
Home ++
Home ++
OPD 0
Home 0
OPD 0
Home ++
Home ++
Home ++
Home +
Home +
Home +
Home ++
Home ++
OPD +
Home ++
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Comprehensive Geriatric Assessment
bull ldquoThe New Technology of Geriatricsrdquo
--Epstein Ann Intern Med 1987
bull Definition ldquoA Multidimensional
interdisciplinary diagnostic process to
identify care needs plan care and improve
outcomes of frail older peoplerdquo
Geriatric Assessment Purposes
Improve diagnostic accuracy
Optimize medical treatment
Improve medical outcomes
Improve function amp quality of life
Optimize living location
Minimize unnecessary service use
Arrange long-term case management
Community Office Clinic
Home Visits
Hospital Special Care
Unit Consult Team
Nursing Home Special Beds
Admission Protocol
GERIATRIC ASSESSMENT WHERE
CGA The Hub of the Geriatric
Care System Rehab or Subacute
Unit
Day Care
Home Care
Respite
Case Mgmt
Nursing Home
Hospital
OPD
Community
CGA
CGA Measurable Dimensions
bull Physical health ndash Traditional history physical exam lab data problem list ndash Disease-specific severity indicators ndash Prevention practices (eg exercise asa vaccination)
bull Functional status ndash ADL amp IADL scales ndash Other functional scales (eg mobility quality of life)
bull Psychological health ndash Cognitive amp affective function scales
bull Socio-environmental parameters ndash Social networks amp supports ndash Economic adequacy ndash Environmental safety amp needs
GERIATRIC ASSESSMENT WHY
Much unreported treatable disease
and disability
Premature nursing home placement
Neglected rehabilitation
Excessive drug useiatrogenesis
Assessment improves outcomes
Benefits of CGA Programs
Diagnosis
Function
Placement
Affect
Cognition
Medications
NH Use
Hospital Use
Costs
Mortality
Randomized Trial of a Hospital Geriatric Evaluation amp Management Unit
Ref Rubenstein et al N Engl J Med 1984 3111664-70
Mortality (24 vs 48 at 1 yr)
NH Use (27 vs 47)
Rehosps (35 vs 50)
Costs ($22K vs $28K yr)
ADL (42 vs 24 at 1 yr)
Morale (42 vs 24 )
The Sepulveda GEM Study
In-Home CGA amp Case Management RCT Copenhagen (Br Med J 1984 2891522-1524)
Program
(N=285)
Controls
(N=287)
196
7
219
4884
30
16
35
261
10
271
6442
60
10
23
P
3-Year Mortality
NH Admissions
Hospital Admissions
Hospital Bed Days
Emergency Dept Visits
Home Help Provision
Home Modifications
lt05
NS
lt01
lt01
lt05
lt05
lt05
Cost of program more than matched by savings
Hospital GEM Programs Published RCTs Reference TypeTarg Significant Impacts
surv fct NHhosp$
surv LOS$(12)
none
survcog drugs
dx(surv)
survfct ( hosp)
fct(surv) NH
affect
none
surv readm
fct NHhosp$
fct NH LOS lab ($)
$ LOS
$ re-adm hosp
satis (surv)
fct satis
fct NH
Rubenstein 84 CA
Collard 85 MA
Allen 86 NC
Hogan 87 Can
Gilchrist 88 UK
Hogan 90 Can
Applegate 90 TN
Fretwell 90 RI
Harris 91 Aus
Thomas 91 NC
Melin 92 Swe
Powers lsquo92 TN
Naughton lsquo94 IL
Naylor lsquo949 PANY
Reuben lsquo95 CA
Karppi lsquo95 Fin
Landefeld lsquo95 OH
Ward++
Ward0
Cons0
Cons+
Ward+
Cons+
Ward++
Cons0
Ward0
Cons0
Cons+fu0
Ward++
Cons++
Cons+fu0
Cons+
Ward+
Ward0
Outpatient GAPs Published RCTs Reference Typefu Significant Impacts
dxfct hosp
surv hosp$(NH)
surv(affect)
hosp$
none
(cog)
NHfalls
surv
(surv) NH(hosp)
survfct hosp
home-surv
fct process
fct NH
fct NH hosp $
surv fct satis
fctcog hosp $
Tullock 79 UK
Hendricksen 84 Den
Vetter 84 UK
Williams 87 NY
Sorensen 88 Den
Epstein 90 RI
Carpenter 90 UK
Vetter 92 UK
Hansen 92 Den
Pathy 92 UK
Hall lsquo94 Can
Fabacher lsquo94 CA
Stuck lsquo95 CA
Melin lsquo95 Swe
Engelhardt lsquo96 NY
Bernabei lsquo98 It
OPD ++
Home ++
Home ++
OPD 0
Home 0
OPD 0
Home ++
Home ++
Home ++
Home +
Home +
Home +
Home ++
Home ++
OPD +
Home ++
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Geriatric Assessment Purposes
Improve diagnostic accuracy
Optimize medical treatment
Improve medical outcomes
Improve function amp quality of life
Optimize living location
Minimize unnecessary service use
Arrange long-term case management
Community Office Clinic
Home Visits
Hospital Special Care
Unit Consult Team
Nursing Home Special Beds
Admission Protocol
GERIATRIC ASSESSMENT WHERE
CGA The Hub of the Geriatric
Care System Rehab or Subacute
Unit
Day Care
Home Care
Respite
Case Mgmt
Nursing Home
Hospital
OPD
Community
CGA
CGA Measurable Dimensions
bull Physical health ndash Traditional history physical exam lab data problem list ndash Disease-specific severity indicators ndash Prevention practices (eg exercise asa vaccination)
bull Functional status ndash ADL amp IADL scales ndash Other functional scales (eg mobility quality of life)
bull Psychological health ndash Cognitive amp affective function scales
bull Socio-environmental parameters ndash Social networks amp supports ndash Economic adequacy ndash Environmental safety amp needs
GERIATRIC ASSESSMENT WHY
Much unreported treatable disease
and disability
Premature nursing home placement
Neglected rehabilitation
Excessive drug useiatrogenesis
Assessment improves outcomes
Benefits of CGA Programs
Diagnosis
Function
Placement
Affect
Cognition
Medications
NH Use
Hospital Use
Costs
Mortality
Randomized Trial of a Hospital Geriatric Evaluation amp Management Unit
Ref Rubenstein et al N Engl J Med 1984 3111664-70
Mortality (24 vs 48 at 1 yr)
NH Use (27 vs 47)
Rehosps (35 vs 50)
Costs ($22K vs $28K yr)
ADL (42 vs 24 at 1 yr)
Morale (42 vs 24 )
The Sepulveda GEM Study
In-Home CGA amp Case Management RCT Copenhagen (Br Med J 1984 2891522-1524)
Program
(N=285)
Controls
(N=287)
196
7
219
4884
30
16
35
261
10
271
6442
60
10
23
P
3-Year Mortality
NH Admissions
Hospital Admissions
Hospital Bed Days
Emergency Dept Visits
Home Help Provision
Home Modifications
lt05
NS
lt01
lt01
lt05
lt05
lt05
Cost of program more than matched by savings
Hospital GEM Programs Published RCTs Reference TypeTarg Significant Impacts
surv fct NHhosp$
surv LOS$(12)
none
survcog drugs
dx(surv)
survfct ( hosp)
fct(surv) NH
affect
none
surv readm
fct NHhosp$
fct NH LOS lab ($)
$ LOS
$ re-adm hosp
satis (surv)
fct satis
fct NH
Rubenstein 84 CA
Collard 85 MA
Allen 86 NC
Hogan 87 Can
Gilchrist 88 UK
Hogan 90 Can
Applegate 90 TN
Fretwell 90 RI
Harris 91 Aus
Thomas 91 NC
Melin 92 Swe
Powers lsquo92 TN
Naughton lsquo94 IL
Naylor lsquo949 PANY
Reuben lsquo95 CA
Karppi lsquo95 Fin
Landefeld lsquo95 OH
Ward++
Ward0
Cons0
Cons+
Ward+
Cons+
Ward++
Cons0
Ward0
Cons0
Cons+fu0
Ward++
Cons++
Cons+fu0
Cons+
Ward+
Ward0
Outpatient GAPs Published RCTs Reference Typefu Significant Impacts
dxfct hosp
surv hosp$(NH)
surv(affect)
hosp$
none
(cog)
NHfalls
surv
(surv) NH(hosp)
survfct hosp
home-surv
fct process
fct NH
fct NH hosp $
surv fct satis
fctcog hosp $
Tullock 79 UK
Hendricksen 84 Den
Vetter 84 UK
Williams 87 NY
Sorensen 88 Den
Epstein 90 RI
Carpenter 90 UK
Vetter 92 UK
Hansen 92 Den
Pathy 92 UK
Hall lsquo94 Can
Fabacher lsquo94 CA
Stuck lsquo95 CA
Melin lsquo95 Swe
Engelhardt lsquo96 NY
Bernabei lsquo98 It
OPD ++
Home ++
Home ++
OPD 0
Home 0
OPD 0
Home ++
Home ++
Home ++
Home +
Home +
Home +
Home ++
Home ++
OPD +
Home ++
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Community Office Clinic
Home Visits
Hospital Special Care
Unit Consult Team
Nursing Home Special Beds
Admission Protocol
GERIATRIC ASSESSMENT WHERE
CGA The Hub of the Geriatric
Care System Rehab or Subacute
Unit
Day Care
Home Care
Respite
Case Mgmt
Nursing Home
Hospital
OPD
Community
CGA
CGA Measurable Dimensions
bull Physical health ndash Traditional history physical exam lab data problem list ndash Disease-specific severity indicators ndash Prevention practices (eg exercise asa vaccination)
bull Functional status ndash ADL amp IADL scales ndash Other functional scales (eg mobility quality of life)
bull Psychological health ndash Cognitive amp affective function scales
bull Socio-environmental parameters ndash Social networks amp supports ndash Economic adequacy ndash Environmental safety amp needs
GERIATRIC ASSESSMENT WHY
Much unreported treatable disease
and disability
Premature nursing home placement
Neglected rehabilitation
Excessive drug useiatrogenesis
Assessment improves outcomes
Benefits of CGA Programs
Diagnosis
Function
Placement
Affect
Cognition
Medications
NH Use
Hospital Use
Costs
Mortality
Randomized Trial of a Hospital Geriatric Evaluation amp Management Unit
Ref Rubenstein et al N Engl J Med 1984 3111664-70
Mortality (24 vs 48 at 1 yr)
NH Use (27 vs 47)
Rehosps (35 vs 50)
Costs ($22K vs $28K yr)
ADL (42 vs 24 at 1 yr)
Morale (42 vs 24 )
The Sepulveda GEM Study
In-Home CGA amp Case Management RCT Copenhagen (Br Med J 1984 2891522-1524)
Program
(N=285)
Controls
(N=287)
196
7
219
4884
30
16
35
261
10
271
6442
60
10
23
P
3-Year Mortality
NH Admissions
Hospital Admissions
Hospital Bed Days
Emergency Dept Visits
Home Help Provision
Home Modifications
lt05
NS
lt01
lt01
lt05
lt05
lt05
Cost of program more than matched by savings
Hospital GEM Programs Published RCTs Reference TypeTarg Significant Impacts
surv fct NHhosp$
surv LOS$(12)
none
survcog drugs
dx(surv)
survfct ( hosp)
fct(surv) NH
affect
none
surv readm
fct NHhosp$
fct NH LOS lab ($)
$ LOS
$ re-adm hosp
satis (surv)
fct satis
fct NH
Rubenstein 84 CA
Collard 85 MA
Allen 86 NC
Hogan 87 Can
Gilchrist 88 UK
Hogan 90 Can
Applegate 90 TN
Fretwell 90 RI
Harris 91 Aus
Thomas 91 NC
Melin 92 Swe
Powers lsquo92 TN
Naughton lsquo94 IL
Naylor lsquo949 PANY
Reuben lsquo95 CA
Karppi lsquo95 Fin
Landefeld lsquo95 OH
Ward++
Ward0
Cons0
Cons+
Ward+
Cons+
Ward++
Cons0
Ward0
Cons0
Cons+fu0
Ward++
Cons++
Cons+fu0
Cons+
Ward+
Ward0
Outpatient GAPs Published RCTs Reference Typefu Significant Impacts
dxfct hosp
surv hosp$(NH)
surv(affect)
hosp$
none
(cog)
NHfalls
surv
(surv) NH(hosp)
survfct hosp
home-surv
fct process
fct NH
fct NH hosp $
surv fct satis
fctcog hosp $
Tullock 79 UK
Hendricksen 84 Den
Vetter 84 UK
Williams 87 NY
Sorensen 88 Den
Epstein 90 RI
Carpenter 90 UK
Vetter 92 UK
Hansen 92 Den
Pathy 92 UK
Hall lsquo94 Can
Fabacher lsquo94 CA
Stuck lsquo95 CA
Melin lsquo95 Swe
Engelhardt lsquo96 NY
Bernabei lsquo98 It
OPD ++
Home ++
Home ++
OPD 0
Home 0
OPD 0
Home ++
Home ++
Home ++
Home +
Home +
Home +
Home ++
Home ++
OPD +
Home ++
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
CGA The Hub of the Geriatric
Care System Rehab or Subacute
Unit
Day Care
Home Care
Respite
Case Mgmt
Nursing Home
Hospital
OPD
Community
CGA
CGA Measurable Dimensions
bull Physical health ndash Traditional history physical exam lab data problem list ndash Disease-specific severity indicators ndash Prevention practices (eg exercise asa vaccination)
bull Functional status ndash ADL amp IADL scales ndash Other functional scales (eg mobility quality of life)
bull Psychological health ndash Cognitive amp affective function scales
bull Socio-environmental parameters ndash Social networks amp supports ndash Economic adequacy ndash Environmental safety amp needs
GERIATRIC ASSESSMENT WHY
Much unreported treatable disease
and disability
Premature nursing home placement
Neglected rehabilitation
Excessive drug useiatrogenesis
Assessment improves outcomes
Benefits of CGA Programs
Diagnosis
Function
Placement
Affect
Cognition
Medications
NH Use
Hospital Use
Costs
Mortality
Randomized Trial of a Hospital Geriatric Evaluation amp Management Unit
Ref Rubenstein et al N Engl J Med 1984 3111664-70
Mortality (24 vs 48 at 1 yr)
NH Use (27 vs 47)
Rehosps (35 vs 50)
Costs ($22K vs $28K yr)
ADL (42 vs 24 at 1 yr)
Morale (42 vs 24 )
The Sepulveda GEM Study
In-Home CGA amp Case Management RCT Copenhagen (Br Med J 1984 2891522-1524)
Program
(N=285)
Controls
(N=287)
196
7
219
4884
30
16
35
261
10
271
6442
60
10
23
P
3-Year Mortality
NH Admissions
Hospital Admissions
Hospital Bed Days
Emergency Dept Visits
Home Help Provision
Home Modifications
lt05
NS
lt01
lt01
lt05
lt05
lt05
Cost of program more than matched by savings
Hospital GEM Programs Published RCTs Reference TypeTarg Significant Impacts
surv fct NHhosp$
surv LOS$(12)
none
survcog drugs
dx(surv)
survfct ( hosp)
fct(surv) NH
affect
none
surv readm
fct NHhosp$
fct NH LOS lab ($)
$ LOS
$ re-adm hosp
satis (surv)
fct satis
fct NH
Rubenstein 84 CA
Collard 85 MA
Allen 86 NC
Hogan 87 Can
Gilchrist 88 UK
Hogan 90 Can
Applegate 90 TN
Fretwell 90 RI
Harris 91 Aus
Thomas 91 NC
Melin 92 Swe
Powers lsquo92 TN
Naughton lsquo94 IL
Naylor lsquo949 PANY
Reuben lsquo95 CA
Karppi lsquo95 Fin
Landefeld lsquo95 OH
Ward++
Ward0
Cons0
Cons+
Ward+
Cons+
Ward++
Cons0
Ward0
Cons0
Cons+fu0
Ward++
Cons++
Cons+fu0
Cons+
Ward+
Ward0
Outpatient GAPs Published RCTs Reference Typefu Significant Impacts
dxfct hosp
surv hosp$(NH)
surv(affect)
hosp$
none
(cog)
NHfalls
surv
(surv) NH(hosp)
survfct hosp
home-surv
fct process
fct NH
fct NH hosp $
surv fct satis
fctcog hosp $
Tullock 79 UK
Hendricksen 84 Den
Vetter 84 UK
Williams 87 NY
Sorensen 88 Den
Epstein 90 RI
Carpenter 90 UK
Vetter 92 UK
Hansen 92 Den
Pathy 92 UK
Hall lsquo94 Can
Fabacher lsquo94 CA
Stuck lsquo95 CA
Melin lsquo95 Swe
Engelhardt lsquo96 NY
Bernabei lsquo98 It
OPD ++
Home ++
Home ++
OPD 0
Home 0
OPD 0
Home ++
Home ++
Home ++
Home +
Home +
Home +
Home ++
Home ++
OPD +
Home ++
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
CGA Measurable Dimensions
bull Physical health ndash Traditional history physical exam lab data problem list ndash Disease-specific severity indicators ndash Prevention practices (eg exercise asa vaccination)
bull Functional status ndash ADL amp IADL scales ndash Other functional scales (eg mobility quality of life)
bull Psychological health ndash Cognitive amp affective function scales
bull Socio-environmental parameters ndash Social networks amp supports ndash Economic adequacy ndash Environmental safety amp needs
GERIATRIC ASSESSMENT WHY
Much unreported treatable disease
and disability
Premature nursing home placement
Neglected rehabilitation
Excessive drug useiatrogenesis
Assessment improves outcomes
Benefits of CGA Programs
Diagnosis
Function
Placement
Affect
Cognition
Medications
NH Use
Hospital Use
Costs
Mortality
Randomized Trial of a Hospital Geriatric Evaluation amp Management Unit
Ref Rubenstein et al N Engl J Med 1984 3111664-70
Mortality (24 vs 48 at 1 yr)
NH Use (27 vs 47)
Rehosps (35 vs 50)
Costs ($22K vs $28K yr)
ADL (42 vs 24 at 1 yr)
Morale (42 vs 24 )
The Sepulveda GEM Study
In-Home CGA amp Case Management RCT Copenhagen (Br Med J 1984 2891522-1524)
Program
(N=285)
Controls
(N=287)
196
7
219
4884
30
16
35
261
10
271
6442
60
10
23
P
3-Year Mortality
NH Admissions
Hospital Admissions
Hospital Bed Days
Emergency Dept Visits
Home Help Provision
Home Modifications
lt05
NS
lt01
lt01
lt05
lt05
lt05
Cost of program more than matched by savings
Hospital GEM Programs Published RCTs Reference TypeTarg Significant Impacts
surv fct NHhosp$
surv LOS$(12)
none
survcog drugs
dx(surv)
survfct ( hosp)
fct(surv) NH
affect
none
surv readm
fct NHhosp$
fct NH LOS lab ($)
$ LOS
$ re-adm hosp
satis (surv)
fct satis
fct NH
Rubenstein 84 CA
Collard 85 MA
Allen 86 NC
Hogan 87 Can
Gilchrist 88 UK
Hogan 90 Can
Applegate 90 TN
Fretwell 90 RI
Harris 91 Aus
Thomas 91 NC
Melin 92 Swe
Powers lsquo92 TN
Naughton lsquo94 IL
Naylor lsquo949 PANY
Reuben lsquo95 CA
Karppi lsquo95 Fin
Landefeld lsquo95 OH
Ward++
Ward0
Cons0
Cons+
Ward+
Cons+
Ward++
Cons0
Ward0
Cons0
Cons+fu0
Ward++
Cons++
Cons+fu0
Cons+
Ward+
Ward0
Outpatient GAPs Published RCTs Reference Typefu Significant Impacts
dxfct hosp
surv hosp$(NH)
surv(affect)
hosp$
none
(cog)
NHfalls
surv
(surv) NH(hosp)
survfct hosp
home-surv
fct process
fct NH
fct NH hosp $
surv fct satis
fctcog hosp $
Tullock 79 UK
Hendricksen 84 Den
Vetter 84 UK
Williams 87 NY
Sorensen 88 Den
Epstein 90 RI
Carpenter 90 UK
Vetter 92 UK
Hansen 92 Den
Pathy 92 UK
Hall lsquo94 Can
Fabacher lsquo94 CA
Stuck lsquo95 CA
Melin lsquo95 Swe
Engelhardt lsquo96 NY
Bernabei lsquo98 It
OPD ++
Home ++
Home ++
OPD 0
Home 0
OPD 0
Home ++
Home ++
Home ++
Home +
Home +
Home +
Home ++
Home ++
OPD +
Home ++
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
GERIATRIC ASSESSMENT WHY
Much unreported treatable disease
and disability
Premature nursing home placement
Neglected rehabilitation
Excessive drug useiatrogenesis
Assessment improves outcomes
Benefits of CGA Programs
Diagnosis
Function
Placement
Affect
Cognition
Medications
NH Use
Hospital Use
Costs
Mortality
Randomized Trial of a Hospital Geriatric Evaluation amp Management Unit
Ref Rubenstein et al N Engl J Med 1984 3111664-70
Mortality (24 vs 48 at 1 yr)
NH Use (27 vs 47)
Rehosps (35 vs 50)
Costs ($22K vs $28K yr)
ADL (42 vs 24 at 1 yr)
Morale (42 vs 24 )
The Sepulveda GEM Study
In-Home CGA amp Case Management RCT Copenhagen (Br Med J 1984 2891522-1524)
Program
(N=285)
Controls
(N=287)
196
7
219
4884
30
16
35
261
10
271
6442
60
10
23
P
3-Year Mortality
NH Admissions
Hospital Admissions
Hospital Bed Days
Emergency Dept Visits
Home Help Provision
Home Modifications
lt05
NS
lt01
lt01
lt05
lt05
lt05
Cost of program more than matched by savings
Hospital GEM Programs Published RCTs Reference TypeTarg Significant Impacts
surv fct NHhosp$
surv LOS$(12)
none
survcog drugs
dx(surv)
survfct ( hosp)
fct(surv) NH
affect
none
surv readm
fct NHhosp$
fct NH LOS lab ($)
$ LOS
$ re-adm hosp
satis (surv)
fct satis
fct NH
Rubenstein 84 CA
Collard 85 MA
Allen 86 NC
Hogan 87 Can
Gilchrist 88 UK
Hogan 90 Can
Applegate 90 TN
Fretwell 90 RI
Harris 91 Aus
Thomas 91 NC
Melin 92 Swe
Powers lsquo92 TN
Naughton lsquo94 IL
Naylor lsquo949 PANY
Reuben lsquo95 CA
Karppi lsquo95 Fin
Landefeld lsquo95 OH
Ward++
Ward0
Cons0
Cons+
Ward+
Cons+
Ward++
Cons0
Ward0
Cons0
Cons+fu0
Ward++
Cons++
Cons+fu0
Cons+
Ward+
Ward0
Outpatient GAPs Published RCTs Reference Typefu Significant Impacts
dxfct hosp
surv hosp$(NH)
surv(affect)
hosp$
none
(cog)
NHfalls
surv
(surv) NH(hosp)
survfct hosp
home-surv
fct process
fct NH
fct NH hosp $
surv fct satis
fctcog hosp $
Tullock 79 UK
Hendricksen 84 Den
Vetter 84 UK
Williams 87 NY
Sorensen 88 Den
Epstein 90 RI
Carpenter 90 UK
Vetter 92 UK
Hansen 92 Den
Pathy 92 UK
Hall lsquo94 Can
Fabacher lsquo94 CA
Stuck lsquo95 CA
Melin lsquo95 Swe
Engelhardt lsquo96 NY
Bernabei lsquo98 It
OPD ++
Home ++
Home ++
OPD 0
Home 0
OPD 0
Home ++
Home ++
Home ++
Home +
Home +
Home +
Home ++
Home ++
OPD +
Home ++
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Benefits of CGA Programs
Diagnosis
Function
Placement
Affect
Cognition
Medications
NH Use
Hospital Use
Costs
Mortality
Randomized Trial of a Hospital Geriatric Evaluation amp Management Unit
Ref Rubenstein et al N Engl J Med 1984 3111664-70
Mortality (24 vs 48 at 1 yr)
NH Use (27 vs 47)
Rehosps (35 vs 50)
Costs ($22K vs $28K yr)
ADL (42 vs 24 at 1 yr)
Morale (42 vs 24 )
The Sepulveda GEM Study
In-Home CGA amp Case Management RCT Copenhagen (Br Med J 1984 2891522-1524)
Program
(N=285)
Controls
(N=287)
196
7
219
4884
30
16
35
261
10
271
6442
60
10
23
P
3-Year Mortality
NH Admissions
Hospital Admissions
Hospital Bed Days
Emergency Dept Visits
Home Help Provision
Home Modifications
lt05
NS
lt01
lt01
lt05
lt05
lt05
Cost of program more than matched by savings
Hospital GEM Programs Published RCTs Reference TypeTarg Significant Impacts
surv fct NHhosp$
surv LOS$(12)
none
survcog drugs
dx(surv)
survfct ( hosp)
fct(surv) NH
affect
none
surv readm
fct NHhosp$
fct NH LOS lab ($)
$ LOS
$ re-adm hosp
satis (surv)
fct satis
fct NH
Rubenstein 84 CA
Collard 85 MA
Allen 86 NC
Hogan 87 Can
Gilchrist 88 UK
Hogan 90 Can
Applegate 90 TN
Fretwell 90 RI
Harris 91 Aus
Thomas 91 NC
Melin 92 Swe
Powers lsquo92 TN
Naughton lsquo94 IL
Naylor lsquo949 PANY
Reuben lsquo95 CA
Karppi lsquo95 Fin
Landefeld lsquo95 OH
Ward++
Ward0
Cons0
Cons+
Ward+
Cons+
Ward++
Cons0
Ward0
Cons0
Cons+fu0
Ward++
Cons++
Cons+fu0
Cons+
Ward+
Ward0
Outpatient GAPs Published RCTs Reference Typefu Significant Impacts
dxfct hosp
surv hosp$(NH)
surv(affect)
hosp$
none
(cog)
NHfalls
surv
(surv) NH(hosp)
survfct hosp
home-surv
fct process
fct NH
fct NH hosp $
surv fct satis
fctcog hosp $
Tullock 79 UK
Hendricksen 84 Den
Vetter 84 UK
Williams 87 NY
Sorensen 88 Den
Epstein 90 RI
Carpenter 90 UK
Vetter 92 UK
Hansen 92 Den
Pathy 92 UK
Hall lsquo94 Can
Fabacher lsquo94 CA
Stuck lsquo95 CA
Melin lsquo95 Swe
Engelhardt lsquo96 NY
Bernabei lsquo98 It
OPD ++
Home ++
Home ++
OPD 0
Home 0
OPD 0
Home ++
Home ++
Home ++
Home +
Home +
Home +
Home ++
Home ++
OPD +
Home ++
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Randomized Trial of a Hospital Geriatric Evaluation amp Management Unit
Ref Rubenstein et al N Engl J Med 1984 3111664-70
Mortality (24 vs 48 at 1 yr)
NH Use (27 vs 47)
Rehosps (35 vs 50)
Costs ($22K vs $28K yr)
ADL (42 vs 24 at 1 yr)
Morale (42 vs 24 )
The Sepulveda GEM Study
In-Home CGA amp Case Management RCT Copenhagen (Br Med J 1984 2891522-1524)
Program
(N=285)
Controls
(N=287)
196
7
219
4884
30
16
35
261
10
271
6442
60
10
23
P
3-Year Mortality
NH Admissions
Hospital Admissions
Hospital Bed Days
Emergency Dept Visits
Home Help Provision
Home Modifications
lt05
NS
lt01
lt01
lt05
lt05
lt05
Cost of program more than matched by savings
Hospital GEM Programs Published RCTs Reference TypeTarg Significant Impacts
surv fct NHhosp$
surv LOS$(12)
none
survcog drugs
dx(surv)
survfct ( hosp)
fct(surv) NH
affect
none
surv readm
fct NHhosp$
fct NH LOS lab ($)
$ LOS
$ re-adm hosp
satis (surv)
fct satis
fct NH
Rubenstein 84 CA
Collard 85 MA
Allen 86 NC
Hogan 87 Can
Gilchrist 88 UK
Hogan 90 Can
Applegate 90 TN
Fretwell 90 RI
Harris 91 Aus
Thomas 91 NC
Melin 92 Swe
Powers lsquo92 TN
Naughton lsquo94 IL
Naylor lsquo949 PANY
Reuben lsquo95 CA
Karppi lsquo95 Fin
Landefeld lsquo95 OH
Ward++
Ward0
Cons0
Cons+
Ward+
Cons+
Ward++
Cons0
Ward0
Cons0
Cons+fu0
Ward++
Cons++
Cons+fu0
Cons+
Ward+
Ward0
Outpatient GAPs Published RCTs Reference Typefu Significant Impacts
dxfct hosp
surv hosp$(NH)
surv(affect)
hosp$
none
(cog)
NHfalls
surv
(surv) NH(hosp)
survfct hosp
home-surv
fct process
fct NH
fct NH hosp $
surv fct satis
fctcog hosp $
Tullock 79 UK
Hendricksen 84 Den
Vetter 84 UK
Williams 87 NY
Sorensen 88 Den
Epstein 90 RI
Carpenter 90 UK
Vetter 92 UK
Hansen 92 Den
Pathy 92 UK
Hall lsquo94 Can
Fabacher lsquo94 CA
Stuck lsquo95 CA
Melin lsquo95 Swe
Engelhardt lsquo96 NY
Bernabei lsquo98 It
OPD ++
Home ++
Home ++
OPD 0
Home 0
OPD 0
Home ++
Home ++
Home ++
Home +
Home +
Home +
Home ++
Home ++
OPD +
Home ++
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
In-Home CGA amp Case Management RCT Copenhagen (Br Med J 1984 2891522-1524)
Program
(N=285)
Controls
(N=287)
196
7
219
4884
30
16
35
261
10
271
6442
60
10
23
P
3-Year Mortality
NH Admissions
Hospital Admissions
Hospital Bed Days
Emergency Dept Visits
Home Help Provision
Home Modifications
lt05
NS
lt01
lt01
lt05
lt05
lt05
Cost of program more than matched by savings
Hospital GEM Programs Published RCTs Reference TypeTarg Significant Impacts
surv fct NHhosp$
surv LOS$(12)
none
survcog drugs
dx(surv)
survfct ( hosp)
fct(surv) NH
affect
none
surv readm
fct NHhosp$
fct NH LOS lab ($)
$ LOS
$ re-adm hosp
satis (surv)
fct satis
fct NH
Rubenstein 84 CA
Collard 85 MA
Allen 86 NC
Hogan 87 Can
Gilchrist 88 UK
Hogan 90 Can
Applegate 90 TN
Fretwell 90 RI
Harris 91 Aus
Thomas 91 NC
Melin 92 Swe
Powers lsquo92 TN
Naughton lsquo94 IL
Naylor lsquo949 PANY
Reuben lsquo95 CA
Karppi lsquo95 Fin
Landefeld lsquo95 OH
Ward++
Ward0
Cons0
Cons+
Ward+
Cons+
Ward++
Cons0
Ward0
Cons0
Cons+fu0
Ward++
Cons++
Cons+fu0
Cons+
Ward+
Ward0
Outpatient GAPs Published RCTs Reference Typefu Significant Impacts
dxfct hosp
surv hosp$(NH)
surv(affect)
hosp$
none
(cog)
NHfalls
surv
(surv) NH(hosp)
survfct hosp
home-surv
fct process
fct NH
fct NH hosp $
surv fct satis
fctcog hosp $
Tullock 79 UK
Hendricksen 84 Den
Vetter 84 UK
Williams 87 NY
Sorensen 88 Den
Epstein 90 RI
Carpenter 90 UK
Vetter 92 UK
Hansen 92 Den
Pathy 92 UK
Hall lsquo94 Can
Fabacher lsquo94 CA
Stuck lsquo95 CA
Melin lsquo95 Swe
Engelhardt lsquo96 NY
Bernabei lsquo98 It
OPD ++
Home ++
Home ++
OPD 0
Home 0
OPD 0
Home ++
Home ++
Home ++
Home +
Home +
Home +
Home ++
Home ++
OPD +
Home ++
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Hospital GEM Programs Published RCTs Reference TypeTarg Significant Impacts
surv fct NHhosp$
surv LOS$(12)
none
survcog drugs
dx(surv)
survfct ( hosp)
fct(surv) NH
affect
none
surv readm
fct NHhosp$
fct NH LOS lab ($)
$ LOS
$ re-adm hosp
satis (surv)
fct satis
fct NH
Rubenstein 84 CA
Collard 85 MA
Allen 86 NC
Hogan 87 Can
Gilchrist 88 UK
Hogan 90 Can
Applegate 90 TN
Fretwell 90 RI
Harris 91 Aus
Thomas 91 NC
Melin 92 Swe
Powers lsquo92 TN
Naughton lsquo94 IL
Naylor lsquo949 PANY
Reuben lsquo95 CA
Karppi lsquo95 Fin
Landefeld lsquo95 OH
Ward++
Ward0
Cons0
Cons+
Ward+
Cons+
Ward++
Cons0
Ward0
Cons0
Cons+fu0
Ward++
Cons++
Cons+fu0
Cons+
Ward+
Ward0
Outpatient GAPs Published RCTs Reference Typefu Significant Impacts
dxfct hosp
surv hosp$(NH)
surv(affect)
hosp$
none
(cog)
NHfalls
surv
(surv) NH(hosp)
survfct hosp
home-surv
fct process
fct NH
fct NH hosp $
surv fct satis
fctcog hosp $
Tullock 79 UK
Hendricksen 84 Den
Vetter 84 UK
Williams 87 NY
Sorensen 88 Den
Epstein 90 RI
Carpenter 90 UK
Vetter 92 UK
Hansen 92 Den
Pathy 92 UK
Hall lsquo94 Can
Fabacher lsquo94 CA
Stuck lsquo95 CA
Melin lsquo95 Swe
Engelhardt lsquo96 NY
Bernabei lsquo98 It
OPD ++
Home ++
Home ++
OPD 0
Home 0
OPD 0
Home ++
Home ++
Home ++
Home +
Home +
Home +
Home ++
Home ++
OPD +
Home ++
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Outpatient GAPs Published RCTs Reference Typefu Significant Impacts
dxfct hosp
surv hosp$(NH)
surv(affect)
hosp$
none
(cog)
NHfalls
surv
(surv) NH(hosp)
survfct hosp
home-surv
fct process
fct NH
fct NH hosp $
surv fct satis
fctcog hosp $
Tullock 79 UK
Hendricksen 84 Den
Vetter 84 UK
Williams 87 NY
Sorensen 88 Den
Epstein 90 RI
Carpenter 90 UK
Vetter 92 UK
Hansen 92 Den
Pathy 92 UK
Hall lsquo94 Can
Fabacher lsquo94 CA
Stuck lsquo95 CA
Melin lsquo95 Swe
Engelhardt lsquo96 NY
Bernabei lsquo98 It
OPD ++
Home ++
Home ++
OPD 0
Home 0
OPD 0
Home ++
Home ++
Home ++
Home +
Home +
Home +
Home ++
Home ++
OPD +
Home ++
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
LOW
bullNon-targeted bullConsult only bullNo follow-up bullLower intensity
HIGH
bullWell-targeted bullClinical control bullFollow-up bullHigher intensity
IMPACTS FROM GAPs
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
CGA Program Meta-Analysis End-of-Study Summary of Findings (Stuck et al Lancet 1993)
GEMU IGCS HAS HHAS OAS Hosp Non-
hosp All-CGA
Mortality 25 NS 21 NS NS 19 17 18
Home 66 np 24 49 NS np 26 25
Function 72 NS NS NS NS np NS np
Cognition 100 71 -- NS NS 79 NS 41
Hosp Use NS NS np NS NS NS np 12
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Updated Cochrane Meta-analysis
Hospital CGA
Eliis G et al Cochrane DB Syst Rev 2011 Jul 6(7)CD006211
22 trials 6 countries N=10315
CGA pts more likely to be alive at home raquo at 6 mos OR 125 95 CI 111-142 p=0002
raquo at 12 mos OR 116 95 CI 104-128 p=003
CGA pts less likely to be raquo Institutionalized OR 79 CI 69-88 plt0001
raquo Dead or deteriorated OR 76 CI 64-90 p=001
Subgroup analysis favors inpatient wards
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
Hospital CGA Living at home at end of follow-up
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Ellis G et al CGA in hospitals meta-analysis of RCTs BMJ 2011
343d6553 doi 101136bmjd6553
Hospital CGA Death at Follow-up (OR 12 mos)
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Preventive Home Visit Program
Meta-Analysis Summary (Stuck et al 1999)
14 Studies (UK-7 USA-3 DK-3 NL-1)
All population-based gt65 (mostgt75)
Visit staff RN-5 HV-5 MD-1 SW-1 lay-2
Effects
Mortality (OR=88 plt05)
NH admissions (OR=84 p=05)
Functional decline (OR=82 p=11)
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Preventive Home Visit Program
Meta-Analysis (2) Covariant Analysis
Mortality Significant only for progs with
control deaths gt8year (OR=8 vs 10)
NH admission Significant only for progs
with gt4 visits (OR = 8 vs 10)
Functional decline Significant only for
progs with CGA (OR =4 vs 11)
(Stuck et al 1999)
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Targeting of Geriatric Assessment (Stuck Egger et al JAMA 2002 2871022-8)
Geriatric assessment according to risk groups
bullFor dependent higher risk older persons
tailored CGA amp follow-up programs
bullFor persons at medium risk aged gt=75
preventive home visits
bullFor persons at low risk aged gt=60
health risk appraisals
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Elderly Population Subgroups
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Caring for Elderly Subgroups
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
ScreeningTargetingCGA System-wide Strategies for Older Persons
All Old Persons
Frail amp
Hi-risk
Hosp
Periodic Screening
Periodic CGA Immediate CGA
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Does CGA Really Work
Why have some trials been negative
Insufficient sample size
Inadequate targeting
Suboptimal outcome measures
Non-implementation of CGA advice limited resources
non-adherence
Improved control group care academic center ldquo2nd-opinionsrdquo
improving geriatric care trends
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Thus CGA programs do improve care
processes and outcomes if done well and on
appropriate patients
But CGA needs to be streamlined and costs
minimized to enhance widespread use
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Improving Geriatric Assessment
Efficiency in the Office Target assessment to patient population
Use self-administered screening forms
Take advantage of hierarchical measures
Use observations amp key informants
Multiple visits where feasiblepreferable
Use available office staff as ldquoteamrdquo
Succinct guidelines for common problems
Printed summaries amp instructions
The ldquo20-minute visitrdquo is possible
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Screening Instruments Functional Status
bull Basic Activities of Daily Living (Katz) 2-3 min
bull Bathing Dressing Getting to toilet
bull Transferring Continence Feeding
bull Instrumental ADLs (Lawton) 2-3 min
bull Shopping Telephoning Preparing meals
Housekeeping Doing laundry Finances
Medications Transportation
bull Advanced ADLs 2-3 min
bull Patient-specific higher function (eg occupation
recreation community service world travel)
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Screening amp Assessment Instruments
Dementia
3-item recall 1-2 min
clock drawing 1-3 min
mini-mental state (30-item) 4-10 min
Depression
single question lt1 min ldquoDo you often feel sad or depressedrdquo
5-item GDS 1-2 min
15-item GDS 3-5 min
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Screening amp Assessment Instruments
Vision ndash Screening Question lt1 min
ldquoDo you have difficulty with driving TV reading or daily
activities because of your eyesight even while wearing
glassesrdquo
ndash Snellen chart (far vision) 1-2 mins
ndash Jaeger card (near vision) 1 min
Hearing ndash Whisper test 1 min
whisper 3 letters 1 foot from ear (fail if lt50 after 3 reps)
ndash W-A Audioscope 1-2 mins 40db (fail if unable to hear 1000hz or 2000hz tones)
ndash Hearing Handicap Inventory 2 min
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Screening amp Assessment Instruments
Malnutrition ndash Screening question 1 min
ldquoHave you lost 10 lbs in past 6 mos without tryingrdquo
ndash BMI (wt in kgheight in meters) 1 min
ndash MNA-short form 1-2 min
ndash Full MNA 5-9 min
Mobility ndash Fall question lt1 min
ldquoHave you fallen to the ground in the past yearrdquo
ndash Timed up-amp-go test 1-2 min
Rise from chair walk 20 ft turn walk back to chair and sit
down (fails if gt15 secs)
ndash Gait amp balance test (Tinetti) 2-3 min
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
History of CGAGEM Programs
1935-1975 1975-1995 1995-2015
Early concepts Refinement Mainstream
amp models amp testing integration
-UK workhouses
-Marjory Warren
-AGSBGSGSA
ldquophilosophiesrdquo
-GEM amp ACE units
-Home visit teams
-Consult services
-Improved ldquousual carerdquo
-Chronic disease
management model
Descriptive papers Controlled trials Meta-analyses
Multi-site trials Addrsquol meta-analyses
UK NHS
VA GRECCs
NIA CGA Conf lsquo83
NIH Consensus Conf lsquo87
AGS-SGIM-ACP reports lsquo88
Kellogg Intrsquol Conf lsquo88
UK NHS GP health chex lsquo90
IAG SOTA Conf ndash Italy lsquo94
Uniform CGA databases (eg MDS RAI)
Capitation managed care
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
What works What doesnrsquot work
bullHospital
-GEM units ++
-Gero-rehabortho ++
-ACE units +
bullHome-visit CGA amp fu ++
bullHospital
-Consult teams alone
bullOutpatient
-Screening alone
-CGA alone
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Newer Geriatric Care Models
bull ACE Units uarr fct uarr home at fu (Baztan BMJ 2009)
bull Geriatric EDs
bull Ortho-geriatric programs
bull Pre-operative CGA
bull Interface geri (p short hosp) NS (Conroy Age Ageing 2011)
bull Post-acute care fu programs
bull Geriatrics in ACOs (accountable care orgs)
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Reorganization of Care in US Healthcare Reform
1deg Care MDs
Spec MDs
Outpt Hosp Care
Inpt Hosp Care
LTACs Inpt Rehab
SNFs HHC Hospice Pal Care
Medical Home
Post-Acute Bundling
Acute care episode w Post Acute Bundling
Acute Care Bundling
Accountable Care Organizations
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
The US Healthcare System
Good resources
High technology
Active research
Choice of provider
Provider flexibility
Relatively high
provider income
Too expensive
Too high-tech
Duplication amp
inefficiency
Inequality
Coverage gaps
Non-planned
ADVANTAGES DISADVANTAGES
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
CGA Remaining Questions
What is are most effective CGA models
Which outcome can CGA most improve
What are key program elements
Who benefits most (Targeting criteria)
How can we make CGA most cost effective
How best to integrate CGA into care system
Will CGA benefits decrease as ldquostandardrdquo care for older persons improves
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Modeling elder healthcare through Education Service amp Research
The Donald W Reynolds Department of Geriatric Medicine
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
bull Initiated in 1997 at VAMC
bull Rapid growth after initial DW Reynolds grant in 1999 ndash Initial mission ldquoto provide premier education for future geriatric
leaders amp providers outstanding service to seniors amp cutting edge aging researchrdquo
ndash One of only 6 full departments of geriatric medicine
bull Currently gt60 FTEE actively involved in education research and clinical care
bull Visionmdashto build a state-wide system of geriatric clinical and educational excellence emanating from OUHSC grounded in an outstanding research program w global reputation amp collaborations
Donald W Reynolds Department of
Geriatric Medicine Brief History
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Donald W Reynolds Department of Geriatric Medicine Components
bull Education
bull Medical (students residents fellows CME)
bull Allied health (nursing pharmacy rehab et al)
bull Community outreach (OHAI)
bull Clinical care
bull Hospital outpatient NH home care
bull Research
bull Basic ndash ROCA
bull Translational applied clinical health services
E
R C
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Extra slideshellip
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Fried amp Hall JAGS 2008
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Preventive CGA visits for home-living
elders Half full or half empty Systematic analysis Haastregt et al (BMJ 2000)
discrepancies ldquono evidencerdquo
Meta-Analysis Elkan et al (BMJ 2001) pooled effect
highly significant ldquohigh level of evidencerdquo
Stuck et al (JAMA 2002 2871022-8) meta-
analysis w meta-regression
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Systematic analysis of 18 trials
with meta-regression analyses
Hypothesized co-variates influencing
outcomes
- targeting independent older persons (EIGER study)
- long-term intervention follow-up (Lancet meta-analysis)
- use of intense multidimensional CGA
Stuck Egger et al JAMA 2002 2871022-8
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
0Soslashrensen (1988)
1 05 (085 to 130)Overal l (95 CI)
4Vetter (1992)
4van Haastregt (2000)
0Hebert (2001)
0Newbury (2001)
5Gunner-Svensson (1984)
090 (075 to 107)Overal l (95 CI)
85Carpenter (1990)
78Tinetti (1994)
75Stuck (2000)
01 02 05 1 2 5 10
12van Rossum (1993)
12Stuck (1995)
066 (048 to 092)Overal l (95 CI)
12Hendriksen (1984)
9Pathy (1992)
0 to 4 follow up visits No of visits
5 to lt 9 follow up visits
gt 9 follow up visits
Risk ratio
Risk of nursing home admission
Stuck et a l JAMA 2002
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Risk ratio
01 02 05 1 2 5 10
Multidimensional assessment
and follow up
van Haastregt (2000)
Fabacher (1994)
Hebert (2001)
Stuck (2000)
Stuck (1995)
Tinetti (1994)
McEwan (1990)
Soslashrensen (1988)
Newbury (2001)
van Rossum (1993)
Pathy (1992)
Clarke (1992)
Vetter (1992)
Carpenter (1990)
Vetter Powys (1984)
Vetter Gwent (1984)
No multidimensional assessment
and follow up
076 (064 to 091)Overal l (95 CI)
101 (092 to 111)Overal l (95 CI)
Figure 3 Stuck et al JAMA 2002
Risk of functional status decline
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
New studies published after meta-
analyses example 1
Cohen HJ al A controlled trial of inpatient and outpatient geriatric evaluation and management (N Engl J Med 2002 346 905 Med Care 2006 44 91)
11 VA centers with established geriatric assessment programs
Frail hosp older persons patients of geriatric program excluded
RCT w cross-over factorial design 1-yr follow-up
UCIP-UCOP (N=348)
UCIP-GEMC (N=346)
GEMU-UCOP (N=348)
GEMU-GEMC (N=346)
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Results at one-year follow-up (Cohen 2002 Schmader 2004 Phibbs 2006)
Survival
UCIP-UCOP 787
UCIP-GEMC 789 ns
GEMU-UCOP 787 ns
GEMU-GEMC 772 ns
Significant effects
GEMU uarr ADL darr NH adm amp days uarr Rx qual
GEMC uarr mental health darr drug reactions
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Limitations of the Cohen trial
raquo Factorial crossover design (possible effect on
processmdashteam did not know if they would be
following their patients)
raquo All sites with established high-quality geriatric
care programs (control care better than usual)
raquo Central control may have affected local team
processes (more complex than co-op drug
studies)
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
New studies published after
meta-analyses example 2
Saltvedt et al Reduced mortality in treating acutely
sick frail older pts in a GEM unit JAGS 2002
50792-8 (Norwegian RCT)
Acute pts gt75 randomized to GEMU or general
medicine wards in Univ of Trondheim Hosp
Mortality GEMU GIM P 3 mo
12 27 004 6 mo 16
29 02 12 mo 28 34 06
No data reported on other outcomes
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
CGA is effective in improving
many important outcomes
BUT
How can it be made more
practical or streamlined
to fit better within
todays medical reality
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Increasing CGA in Todays Reality Proposals
bull Multi-level targeting
screening rarr casefinding rarr CGA
bull Streamlined CGA approach
bull Recapturing cost savings
bull Integrated follow-up case-management system
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Geriatric Ambulatory Care Keys to Success
Comprehensive assessment
Interdisciplinary team approach
Provider continuity
Case management amp follow-up
Home support system phone contacts
meals-on-wheels home visits etc
Enthusiasm
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Hospital GEM Units Types Acute care units
most costly amp intensive handles ldquooutliersrdquo MD or RN run
Subacute care units longer LOS team care CGA amp rehab
Rehabilitation units stroke orthopedic or general rehab
Mixed units efficient space use swing beds issues of identity amp
balance
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Advantages of the Home Visit for
Geriatric Assessment
Observation of function at home
Observe environment access safety
Nutritional adequacy
Medication inventory
Social supports amp interactions
Elder abuse risks
Needs for adaptive equipment
Homemaker needs
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Key Observations During the
Home Visit Examples
Garden well tended
Entriesexits accessible
Refrigerator food quantity amp quality
Medicines polypharmacy current
Safety water temp smoke alarm floor
hazards (cords rugs clutter) rails
(bathroom stairways)
General temperatureinsulation
cleanliness lighting
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
1 in 12 8
1 in 5 20
US Population Growth
1 in 8
12
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
The Irsquos of Geriatrics
Instability (falls)
Incontinence
Intellectual impairment (dementia)
Iatrogenesis (polypharmacy)
Incoherence (delirium)
Insulin resistance (diabetes)
Immobility
Irritability (depression)
Inanition (malnutrition frailty)
Impoverishment
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
The whole world is aging
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Life spans in developed countries have risen dramatically
689 692
675 665
691
660
639
773 783 786
794 797 800
819
60
65
70
75
80
85
US UK Germany France Canada Italy Japan
Years
1950-1955 2000-2005
Life Expectancy at Birth by Country
Source UN (2005)
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Changing Mortality Causes
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
435
400
8575
5543
2920 17
0
50
100
150
200
250
300
350
400
450
500
Tobacco Poor dietinactivity
Alcohol Microbial agents
Toxic agents Motor Vehicle Firearms Sexual behavior
Illicit drug use
(Tho
usand
s)
Actual Causes of US Death - 2000
Mokdad AH Marks JS Stroup DF Gerberding JL Actual causes of death in the United States 2000 JAMA
20042911238-1245
Modifiable Causes of US Deaths ndash 2000
44 of All Deaths
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Hospital Use Increases with Age Annual US Hospital Discharges per 100 persons 1991
0
5
10
15
20
25
30
35
40
45
15-44
45-64
65-74
75+
Data from Health United States 1992 USPHS
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Hospital Discharge Locations of Discharges by Age Males 1987 US Data (NCHS 1993)
0
10
20
30
40
50
60
70
80
90
Home NH Died
55-64
65-74
75-84
85+
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Physician Visits uarrwith Age Mean noyr 2003-4 (NCHS 2006)
0
1
2
3
4
5
6
7
8
9
Males Females
45-54
55-64
65-74
74+
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Health Service $ uarrwith Age Per capita expenditures in $1000s 1987 US Data (NCHS 1993)
0
1
2
3
4
5
6
7
8
9
65-69 70-74 75-79 80-84 85+
Other
NHs
MDs
Hospitals
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Health Care Expenditures
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Functional Limitations
ADL Bathing dressing eating transfering walking toileting IADL Telephone housework meal prep shopping managing money
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Per Capita Health Spending in 2006
Source McKinsey Global Institute and NEJM 2009
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Percent Health Care of GDP 2006
data from WHO httpwwwwhointen
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Why is US Healthcare So Costly
bull Technology emphasis
bull Higher prices and wages
bull Price insensitivity amp supply-driven incentives (ldquofee for servicerdquo)
bull Valuesculture
bull Supplemental insurance
bull Inefficiency amp lack of care coordination
bull Poor lifestyle choices
bull Fear of litigation (ldquodefensive medicinerdquo)
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Geriatrics Founders amp Leaders
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Source ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine Available at wwwADGAPstudyucedu Accessed April 8 2008
11423 11121
2412
4089
5940
8824
10858 10530
10215 9915 9701
9474 9263
8279
7128 7138 6875
7735 7420
7976 7762
8354 8143
8824 8279
5940
4089
2412
0
2000
4000
6000
8000
10000
12000
1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006
Cumulative Certificates awarded Currently Certified Geriatricians
Number of Geriatricians
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
GSA to Co-host The 2017 International Association of
Gerontology amp Geriatrics (IAGG) World Congress
Save the Date
July 23-27 2017
Moscone Center
San Francisco California
ldquoGlobal Aging and Health Bridging Science Policy and Practicerdquo
Web site launches June 2013
Visit iagg2017org and sign up to receive future IAGG2017 news
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Brief Timeline of US Geriatrics
Current Scene
7200 Certified Geriatriciansmdashtoo few Universal health insurance (Medicare)
LTC NH homecare daycare New Rx benefit Hospice coverage
Prevention benefits PACE programs
Developmental Phase
1974 NIA 1975 VA GRECCs 1978 IOM report ldquoAging amp Med Educationrdquo 1978
VA geriatrics fellowships
1980s Recognition of geriatric syndromes amp CGA
1988 Geriatrics Board Certification
Early Days
1909 Dr Nascher coins term ldquogeriatricsrdquo 1914 publishes first text
1930s British take lead in developing field Marjory Warren describes her
successes in chronic hospitals
1939 GSA 1942 AGS 1946 J Gerontology 1953 JAGS
1964 Medicare
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
Newer Meta-analysis Hosp CGA Programs (Ellis amp Langhorne Brit Med Bull 2005 7145)
uarr hospital CGA RCTs (13 rarr 20) 10 GEMU 10 IGCS
End-of-study mortality became NS OR = 095 (95 CI 087-105 n=10427)
Living at home 6 mo 12 mo GEMU 180 (13-25) 168 (12-24)
GEMU + IGCS 126 (104-15) 147 (11-19)
4 extra pts alive amp at home per 100 treated (95 CI 1-7)
No new data on uarrfunction amp uarrcognition
