Geriatric co-management: where is the evidence?

Bastiaan Van Grootven is a PhD researcher at the KU Leuven – University of Leuven in Belgium. His paper Effectiveness of in-hospital geriatric co-management: a systematic review and meta-analysis has recently been published in Age and Ageing. He tweets at @accentvv

Hospitals have long been recognized as a hazardous environment for frail patients. To date, care is still sub-optimal: cognitive and functional problems are not recognised or treated properly and patients are at high risk for delirium and functional decline. In our study, we reviewed 12 experimental studies to evaluate if geriatric co-management can improve outcomes for older in-patients. Co-management was defined as a shared responsibility and decision making between a medical doctor (e.g. surgeon) and geriatrician (or geriatric team) aiming to prevent and treat geriatric complications.

What were the results?

Co-management reduced hospital length of stay and the number of complications and improved the functional status of patients. However, when we look at the consistency of effects across studies and the potential of biased results in the studies, we are not sure how genuine these effects are. Interestingly, there was some evidence for preventing in-hospital mortality. This effect was more pronounced in studies with a stronger methodology and/or reporting interdisciplinary team collaboration, but the evidence was weak. There was insufficient data to conclude anything about post-discharge effects.

What can we conclude about geriatric co-management?

We should be careful to promote the large-scale implementation of this model of care. The current body of evidence is too biased and important outcomes like functional status and cognition have hardly been measured. Nonetheless, looking across all the different types of studies, it is hard to ignore the accumulation of success in co-management programmes. For example, numerous observational studies have also demonstrated a reduced time to surgery and length of stay and less complications for hip fracture patients. In that sense the safest conclusion should be that co-management is an effective strategy to improve care for older patients, but at this point it is highly uncertain if the improvement will be cost-effective on patient outcomes.

The future of geriatric co-management

Further evaluation is needed as cluster-randomised multicenter studies and prospectively powered studies reporting patient-centered outcomes are still lacking. We should aim to understand which intervention components make programs successful and how this success is influenced by certain contextual factors. Lastly, we should aim to understand in which patients geriatric co-management is most effective. Although most co-management programmes have been evaluated in older hip fracture patients, there are no indications that co-management should not work in non-fracture patient groups. For example, our own team is currently starting a cardio-geriatric co-management programme for frail patients admitted to an acute cardiology ward (NCT02890927). Our preliminary data demonstrates that 60% of our older patients admitted with an acute cardiovascular disease are physically frail.

In conclusion, geriatric co-management studies have been successful in improving care for older in-patients. However the current evidence is not strong enough to conclude that all future co-management programs will be cost-effective.

Read the Age and Ageing paper: Effectiveness of in-hospital geriatric co-management: a systematic review and meta-analysis  

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