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Acute Geriatric Units: An Incomplete Story?
- Graham Ellis, Martin Whitehead, David Robinson, Desmond O’Neill and Peter Langhorne (6 February 2009)
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It is the 30th Birthday of “Evidence Based Medicine” and Time to Meet Cochrane’s Challenge.
- Tony KF Chow (13 February 2009)
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Author's reply
- Juan J. Baztán, Francisco M Suárez-García, Jesús López-Arrieta, Leocadio Rodríguez-Mańas, Fernando Rodríguez-Artalejo (22 February 2009)
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Graham Ellis, Consultant Geriatrician Monklands Hospital, Monkscourt Avenue, Airdrie, Lanarkshire, ML6 0JS, Martin Whitehead, David Robinson, Desmond O’Neill and Peter Langhorne
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Sir, We note with interest the recent paper on Acute Geriatric Units by Baztán et al (1). The evidence base for the care of older people is growing at an encouraging rate. Baztan’s paper leaves some unanswered questions regarding the evidence base for the hospital care of older people. Methodologically we would be interested to know why the authors have chosen not to include two randomised controlled trials (2,3) which evaluate the impact of an Acute Care for Elders ward with comprehensive Geriatric assessment. Analysis of data for the outcome of ‘Living at Home’, including published data from these studies suggest a more significant benefit than that described in the paper (OR 1.20, 95% CI 1.05 – 1.38, p=0.008). Secondly, whilst the authors explain their justification for the distinction between Acute Geriatric Units and Geriatric Evaluation and Management Units, and whilst the optimal timing of Comprehensive Geriatric Assessment remains a valid question, the distinction between these two may be considered to be splitting hairs. For example, one study (not included in their paper) appeared to evaluate patients admitted within 72 hours (4), and the remainder of randomised controlled trials evaluated admission from 72 hours onwards (5-9). Finally, while the evidence of benefit for Acute Geriatric Units is clear, there remains uncertainty as to whether Comprehensive Geriatric Assessment is appropriate for all patients over 65 (including independent patients or those with mono-pathology, as opposed to those with evidence of frailty, disability or multiple morbidity). Comprehensive Geriatric Assessment for this latter group may have a greater effect size, contributing to the overall evidence of benefit without necessarily demonstrating benefit for more independent patients. It seems to us that whilst the question of “when” is important for Geriatric care, the more complex and fundamental question of “who” remains unanswered. Future research into acute inpatient Geriatric Assessment should also focus on whether or not it is possible to accurately identify frail and at risk groups, given current evidence that generalists frequently fail to identify frailty and co-morbidity in older people. Graham Ellis, Martin Whitehead, David Robinson, Desmond O’Neill, Peter Langhorne (1) Juan J Baztán, Francisco M Suárez-García, Jesús López-Arrieta, Leocadio Rodríguez-Mańas, and Fernando Rodríguez-Artalejo Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis BMJ 2009; 338: b50 (2) Marsha D. Fretwell, Patricia M. Raymond, Stephen T. McGarvey, Norma Owens, Mark Traines, Rebecca A. Silliman, Vincent Mor. The Senior Care Study. A Controlled Trial of a Consultative/Unit-Based Geriatric Assessment Program in Acute Care. JAGS 1990; 38:1073-1081 (3) Powell C., Montgomery P.. The Age Study: The Admission of Geriatric Patients Through Emergency. Age&Ageing 1990;19(Suppl) 21 (4) Thorsten Nikolaus, Norbert Specht-Leible, Matthias Bach, Peter Oster, Guenter Schlierf. A Randomized Trial of Comprehensive Geriatric Assessment and Home Intervention in the Care of Hospitalized Patients. Age&Ageing 1999; 28:543-550 (5) William B. Applegate, Stephen T. Miller, Marshall J. Graney, Janet T. Elam, Robert Burns, Derene E. Akins. A Randomized, Controlled Trial of a Geriatric Assessment Unit in a Community Rehabilitation Hospital. NEJM 1990; 322(22): 1572-1578 (6) Harvey J. Cohen, John R. Feussner, Morris Weinberger, Molly Carnes, Ronald C. Hamdy, Frank Hsieh, Ciaran Phibbs, Philip Lavori. A Controlled Trial of Inpatient and Outpatient Geriatric Evaluation and Management. NEJM 2002; 346(12): 905-912 (7) Gloria Kay, Marilyn MacTavish, Carol Moffat, Godwin Lau. Development and Evaluation of a Geriatric Assessment Unit in a Community Hospital. Fall 1992; 16(3): 2-9 (8) Laurence Z. Rubenstein, Karen R. Josephson, G. Darryl Wieland, Patricia A. English, James A Sayre, Robert L. Kane. Effectiveness of a Geriatric Evaluation Unit. NEJM 1984; 311: 1664-1670 (9) Ingvild Saltvedt, Ellen-Sofie Ophdahl, Peter Fayers, Stein Kaasa, Olav Sletvold. Reduced Mortality in Treating Acutely Sick, Frail Older Patients in a Geriatric Evaluation and Management Unit. A Prospective Randomized Trial. JAGS 2002; 50: 792-798 Competing interests: All authors are involved in a Cochrane Review Of Comprehensive Geriatric Assessment for Older Adults Admitted to Hospital |
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Tony KF Chow, Staff Anaesthetist Box Hill Hospital, Box Hill, Victoria, Australia 3128
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My congratulations to Baztán et al.1 for their systematic review regarding the effectiveness of acute geriatric units compared with conventional care units. Congratulations must also be extended to the authors who conducted the randomised controlled trials referenced within the review. It is exactly 30 years since Archie Cochrane uttered the following words that sparked the “Evidence Based Medicine” movement: “It is surely a great criticism of our profession that we have not organised a critical summary, by specialty or subspecialty, adapted periodically, of all randomised controlled trials.”2 Despite the efforts of Baztán et al. and many others however, clearly we have yet to fulfil Cochrane’s challenge. In particular, we are bogged down by methods used to identify the quality randomised trials that enable periodic updating of the reviews. With all due respect to Baztán et al. the method detailed in Appendix 1 has not been validated and is neither sensitive nor specific enough to ensure that sufficient randomised trials were identified and that non- randomised trials were excluded. Traditionally, the gold standard included hand searching of journals and scanning the reference list of reviews and relevant articles. This is then supplemented by computer searches of MEDLINE, EMBASE and the Cochrane central register of controlled trials. Hand searching journals is time consuming and expensive, and it is difficult, if not impossible, to duplicate the search to validate the original authors’ results. Knipchild3 had demonstrated 15 years ago, after conducting an extra-ordinary hand search regarding the effectiveness of vitamin C, that the majority of quality randomised trials were listed in computer databases. Over the pass decade, the information technological advances have rendered hand searching redundant. In terms of computer searches the Cochrane Collaboration’s protocol recommends the Optimally Sensitive Search Strategy (OSSS), a 29-line algorithm shown to be highly sensitive but lacking specificity.4 The OSSS casts a very wide net and hence a significant number of articles identified are non-randomised trials and are not of sufficient quality for review. My co-workers and I suggest a simpler solution: (double blind$ or random$).af. This single-line algorithm applied to MEDLINE and EMBASE identifies a sufficient number of randomised trials (greater than 95%) compared with the number identified in the original reviews, to draw the same conclusions.4 In comparison with Baztán et al.1 the search strategy described in Table 1 creates a readily reproducible database that resulted in 1045268, 104039 and 8355 articles respectively. Table 1. Search Strategy 1. (double blind$ or random$).af. 2. geriatric.af. 3. 1 and 2 Advanced Ovid Search conducted on the 12th of February with EMBASE 1980 to Week 6 and Ovid MEDLINE 1950 to February Week 1 2009. This database identified all six of the quality randomised trials (w1 -w6) that were included for meta-analyses, whilst excluded five (w7-w11) of the six non-randomised trials. The latter is consistent with our original reported specificity of 98% (i.e., every 100 articles identified two were non-randomised trials)4 The advanced OVID search labels within MEDLINE and EMBASE were used to develop (double blind$ or random$).af. This strategy assumes that double blinded, randomised controlled trials will be indexed with “double- blind,” “random,” or variations of these terms. This algorithm identifies specific terms with unlimited truncation (e.g., “double-blinded,” “double- blinding,” “randomly,” “random allocation,” “randomized,” “randomised,” “randomization,” “randomisation,” and “randomized controlled trial”). Conversely, non-randomised studies are excluded because they should not be indexed with the above-mentioned terms. If we are to truely meet Cochrane's Challenge, my co-workers and I believe that systematic reviewers should agree upon a search strategy such as (double blind$ or random$).af. in order to expedite the summary and periodically update these valuable systematic reviews. References: Baztán JJ, Suárez-Garciá FM, López-Arrieta J, Rodŕiguez-Mańas L, Rodŕguez-Artalejo F. Effectiveness of acute geriatric units on functional decline, living at home and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis. BMJ 2009;338:b50doi:10.1136/bmj.b50 2. Cochrane AL. 1931-1971: a critical review, with particular reference to the medical profession. In: Medicines for the year 2000. London: Office of Health Economics, 1979:1-11 3. Knipschild P. Systematic reviews. Some examples. BMJ 1994;309(6956):719-21 4. Chow TKF, To E, Goodchild CS, McNeil JJ. A simple, fast, easy method to identify the evidence base in pain relief research: validation of a computer search strategy used alone to identify quality randomized controlled trials. Anesth Analg 2004;98:1557-65 Competing interests: None declared |
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Juan J. Baztán, consultant geriatrician Hospital Central Cruz Roja; Avda R. Victoria 26; 28003-Madrid (Spain), Francisco M Suárez-García, Jesús López-Arrieta, Leocadio Rodríguez-Mańas, Fernando Rodríguez-Artalejo
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RESPONSE (to Dr. Ellis et al and to Dr. Chow) We thank Dr. Ellis and cols. for their interest and comments on our study (1). The aim of our review was to evaluate the effectiveness of care at Acute Geriatric Units (AGUs) independently of subacute and post- discharge care. Although total clinical benefit derive from the availability, continuity and coordination of all specialized healthcare, the assessment of partial interventions contributes to establish specific benefits of each type of geriatric care. For this reason we excluded studies where interventions did not focus the acute phase of disease, such as Nikolaus‘ study where the in-patient care was followed by a post- discharge intervention (2). In the same way, we excluded the AGE study (after obtaining non-published data from the authors), since the intervention unit, with a hospital stay of 43 days, provided acute as well as subacute care (3). Most trials in the acute phase of hospitalization have assessed the work of geriatric teams, whose main difference with AGUs is a lack of an own hospital ward and of direct responsibility for patient care. The Senior Care Study (4) was excluded because we classified it as geriatric team-based intervention, as other reviews did (5,6). To ensure homogeneity across trials, we also excluded the trial by Saltvedt et al (7) because it studied patients recruited 3 or more days after hospital admission. Had this study been incorporated into the meta- analysis, results would have been similar, showing tan patients in AGUs have an increased likelihood of living at home at discharge (OR=1.30; 95% CI 1.12 to 1.51; I2=0%), and at 3 months after discharge (OR=1.33; 95% CI 1.02 to 1.72), but at the expense of increasing heterogeneity (I2=56%). Our study did not aim to identify the characteristics of the patients who get more benefit from AGUs, though age 70-y or older was an inclusion criteria in 4 out of five of the trials reviewed. It is plausible that the oldest patients are precisely those who obtain the greater benefit from AGUs, because as age increases so does functional impairment, which is one of the main risk factors for mortality and institutionalization (8,9). We agree with Dr. Ellis and cols. in that more trials are needed to test this hypothesis, and to examine whether the effectiveness of AGUs varies with frailty, disability or co-morbidity. We also thank Dr. Chow for his comments on our paper. His parallel bibliographic search suggests that we have not missed any important study. Juan J Baztán, Francisco M Suárez-García, Jesús López-Arrieta, Leocadio Rodríguez-Mańas, Fernando Rodríguez-Artalejo (1) Juan J Baztán, Francisco M Suárez-García, Jesús López-Arrieta, Leocadio Rodríguez-Mańas, and Fernando Rodríguez-Artalejo Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis BMJ 2009; 338: b50 (2) Thorsten Nikolaus, Norbert Specht-Leible, Matthias Bach, Peter Oster, Guenter Schlierf. A Randomized Trial of Comprehensive Geriatric Assessment and Home Intervention in the Care of Hospitalized Patients. Age&Ageing 1999; 28:543-550 (3) Powell C., Montgomery P.. The Age Study: The Admission of Geriatric Patients Through Emergency. Age&Ageing 1990;19(Suppl) 21 (4) Marsha D. Fretwell, Patricia M. Raymond, Stephen T. McGarvey, Norma Owens, Mark Traines, Rebecca A. Silliman, Vincent Mor. The Senior Care Study. A Controlled Trial of a Consultative/Unit-Based Geriatric Assessment Program in Acute Care. J Am Geriatr Soc 1990; 38:1073-1081 (5) Andreas E Stuck, Albert L Siu, G Darryl Wielad, John Adams, Laurence Z Rubenstein. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993; 342: 1032-6. (6) Graham Ellis, Peter Langhorne. Comprehensive geriatric assessment for older hospital patients. British Med Bull 2005; 71: 45-9. (7) Ingvild Saltvedt, Turi Saltnes, Ellen-Sofie Opdahl-Mo, Peter Fayers, Stein Kaasa, Olav Sletvold. Acute geriatric intervention increases the number of patients able to live at home. A prospective randomized study. Aging Clin Exp Res 2004; 16: 300-6. (8) Kenneth E Covinsky, Robert M Palmer, Richard H Fortinsky, Steven R Counsell, Anita L Stewart, Denise M Kresevic et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc 2003; 51: 451-8. (9) Richard H Fortinsky, Kenneth E Covinsky, Robert M Palmer, C Seth Landefeld. Effects of functional status changes before and during hospitalization on nursing home admission of older adults. J Gerontol A Biol Sci Med Sci 1999; 54: M521-6 Competing interests: None declared |
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