Comprehensive Care – NIHR themed review of research into older people with frailty in hospitals

John Gladman is Professor of the Medicine of Older People, Division of Rehabilitation and Ageing and Honorary Consultant in Health Care of Older People at Nottingham University Hospitals NHS Trust.

Vast sums are spent on research into the care of older people, but they are wasted if the findings are not put into practice.

I had an epiphany a few years ago. I looked at my carefully curated curriculum vitae, and noted that I had over 100 peer reviewed papers to my name. But I suddenly felt deflated when I realised that hardly anybody (apart from the journals’ editors) had ever read them. Deflation was followed by shame as I realised that I had made no effort to disseminate my findings to those who might find them useful, or to encourage the application of the findings in practice. I recovered a bit when I realised that it wasn’t just me. There is a real problem as the amount of research being published is monstrously huge. But I returned to shame again when I thought about how little effort I have taken to ensure that I keep up to date with other people’s research.

The academic and clinical communities have been aware of this problem for some time. In 2001, the Institute of Medicine, in its report Crossing the Quality Chasm¹, stated that it now takes an average of 17 years for new evidence to be incorporated into practice. Part of the problem (but certainly not all of it) is that research findings are placed in academic journals, often obscure ones, written to placate peer reviewers, and not read by the potential users of the research such as busy practitioners, managers, commissioners, patients or their carers. So what should we do?

The NHS research arm, the National Institute of Health Research, funds lots of health research and is well aware of this problem. In 2015 it set up the NIHR Dissemination Centre, which provides short and accessible summaries of recently finished studies but also writes themed reviews of its current and recently completed research on given topics. In early 2017, a review of research conducted in care homes called Advancing Care was published, and at the end of 2017 a themed review of research into the acute hospital care of older people with frailty, Comprehensive Care, was published. Elaine Maxwell from the dissemination centre curated the themed review (and also helped with this blog), and I was delighted to be one of the many researchers asked to contribute to it. It’s a slim volume and is easily accessible, tracing research in older people with frailty before they get into hospital, through the emergency phase, the hospital admission and to aftercare.

To me, it shows that the care of older people is not a boring old backwater anymore (if it ever was), but an area brimming with innovation and invention. Gone are the days of futile debates about age cut-offs for treatments – we now have the notion of frailty to understand the catastrophic responses we see in our vulnerable patients. Andy Clegg and colleagues paper on the electronic frailty index is one of many studies in this review, one that is set to become a classic alongside Stuck’s Lancet meta-analysis of comprehensive geriatric process². In the report, we see CGA being re-affirmed and elaborated, extended into acute care and dementia care. We are given a heads up that Stuart Parker and Simon Conroy’s Hospital Wide CGA study is near to completion, so we can look out for it.  The review also includes the state of current knowledge on managing the five frailty syndromes on busy hospital wards and the important of good planning for transitions to the next stage of care.

Follow the links and take a look at the NIHR Dissemination portal and Comprehensive Care in particular. What resonates with you? What surprises you? What might you do differently? Let’s hope that it does not take 17 years before we put this research into practice.

• Institute of Medicine (2001) Crossing the Quality Chasm: A new health System for the 21^st Century Washington DC: National Academies Press

• Stuck, A.E., Siu, A.L., Wieland, G.D., Rubenstein, L.Z. and Adams, J., (1993) Comprehensive geriatric assessment: a meta-analysis of controlled trials. The Lancet 342(8878), pp.1032-1036.