An evidence-based and stakeholder-informed approach to advancing comprehensive geriatric assessment models of care in emergency and acute care settings

Background

Comprehensive geriatric assessment (CGA) is considered the reference standard approach to improving a range of outcomes for hospitalised older adults living with frailty. To date, the delivery and impact of CGA in the emergency department (ED) has not been extensively studied.

Aim

This thesis aimed to identify and develop the evidence base for CGA models of care in emergency and acute care settings.

Methods

First, an updated systematic review and meta-analysis synthesised the totality of evidence regarding the effectiveness of acute geriatric unit (AGU) care among hospitalised older adults with acute medical complaints. Second, a qualitative systematic review and meta-ethnography synthesised stakeholders’ experiences of CGA in an inpatient hospital setting. Third, a prospective cohort study explored the longitudinal outcomes of older adults who received CGA in the ED of a university teaching hospital in Ireland. Lastly, a national consensus building study established the core elements of a frailty at the front door (FFD) model of care using a modified real-time Delphi technique. This programme of research is aligned with contemporary models of successful ageing and is underpinned by the principles of Public and Patient Involvement (PPI).

Results

The updated systematic review and meta-analysis identified that AGU care was associated with a reduction in functional decline at six-month follow-up and an increased probability of living at home at three-month follow-up. The meta-ethnography illustrated a reciprocal and refutational synthesis, reflective of the disparate experiences of CGA across stakeholder groups. The prospective cohort study found that CGA in the ED may improve outcomes by mitigating against the adverse effects of potentially avoidance hospital admission and focusing on integration of services across the continuum of care. Finally, development of a consensus derived FFD model of care represents an important step in generating national standards, implementation of a service model as intended, and enhances opportunities for scientific impact.

Conclusion

The findings and unique contributions arising from this thesis aim to inspire the design and delivery of evidence-based CGA models of care with a particular focus on identifying the optimum target population, operational models of CGA, core intervention components, and outcomes of interest. Future research should continue to operationalise effective PPI and evaluate the fidelity of CGA models of care through completion of process evaluations.