This article provides a review of studies evaluating geriatric assessment teams in both inpatient and outpatient settings.

Geriatric Assessment Teams

In 1985, Epstein and colleagues⁴ surveyed 114 geriatric assessment teams in the United States. Questionnaires were mailed requesting information about development, size, location, staffing patterns, sources of referral, patient care activities, and opinions about the impact of geriatric assessment teams on patient outcomes.

Forty-seven percent of the teams were developed after 1983, and only 14% were established prior to 1979. Although most of the teams were located within acute care hospitals, 61% of the teams provided care primarily to outpatients. Other locations included chronic care hospitals, neuropsychiatric centers, and ambulatory care centers. Physicians were included on all the teams, with only half of the physicians having formal education in geriatrics. Other staff varied among the teams, with nurses and social workers being present on most inpatient teams. However, nurses and social workers were included slightly less frequently on the outpatient teams.

Sources of referral to the outpatient assessment teams can be divided into five main categories, each with approximately equal percentages: self or friend, social service agencies, physician, hospital, and long-term care facilities. Most teams served as the primary caregiver to the patient, as well as being a consultant to other health care professionals who provided patient care.

Services varied widely among the sites surveyed by Epstein. Some assessments were conducted using a standard protocol, and some used printed forms or published instruments only. The average number of hours spent per patient per visit was 2.7, and approximately three personnel saw the patient per visit. Most of the teams surveyed believed they had a positive impact on patient care. They ranked the diagnosis of treatable conditions highest in terms of impact, while optimization of social supports was ranked lowest. More than half of the teams believed their care was moderately more effective or much more effective than routine care, especially with regard to the ability of assessment teams to diagnose new, treatable problems and to improve drug regimens.

Epstein's survey yielded three important observations. First, outpatient assessment teams were more prevalent than inpatient teams. Second, only half of the physicians engaged in geriatric assessment functions had formal training in the field of geriatrics. Third, assessment functions varied greatly among the teams.

Inpatient Research Trials

A more recent trial by Reuben and colleagues⁷ randomized 2,353 patients from four hospitals to receive either geriatric assessment or usual care. While the assessment team recommended many medication changes, rehabilitation programs, and diagnostic tests, one-year survival was similar between the two groups, and health and functional status were identical for the groups at both three and 12 months. The authors concluded that geriatric assessment did not improve health or survival in these patients. However, in this study, assessment consisted of an initial consultation and recommendation, with limited follow-up. Assessment was diagnostic and not therapeutic. The short length of the study and the primary caregivers' failure to implement the team's recommendations may explain study findings.

A meta-analysis of six studies examining inpatient geriatric assessment teams was conducted in 1993 by Stuck and colleagues.⁸ Positive outcomes were found for individuals who received comprehensive inpatient assessment. Patients included in the studies experienced less mortality and improved physical and cognitive function, and they transitioned to higher levels of independence than patients who received usual care.

Outpatient Research Trials

A number of trials have been conducted with outpatient assessment teams. These are summarized in Table 3.

In 1979, Tulloch and Moore⁹ randomized 295 patients either to usual care or to an initial exam with a two-year follow-up in a clinic staffed by a physician, nurse, and other health care staff. While there was an increase in the number of hospital admissions for the assessment group, the total number of bed days was actually lower.

A greater number of medical problems were diagnosed and treated in the assessment group. Interestingly, the researchers found no differences in functional capacity between the groups. Also, as a result of the intervention, the patients who received the assessment used more social health services, which may imply increased short-term health care costs.

In 1987, Williams et al.¹⁰ randomized 117 patients aged 65 or older to receive multidisciplinary team assessment or routine care. At one year, while the number of admissions were higher in the assessment group, the total number of bed days was lower and hospital costs were 25% lower, although this was not statistically significant. Moreover, there was no difference between the two groups in terms of patient satisfaction or functional improvement.

That same year, Yeo et al.¹¹ reported on 205 VA patients randomized to geriatric assessment teams or usual care. At 18 months, there appeared to be less decline in functional health for the assessment groups, as measured by the impact of illness on functioning. However, there were no differences in psychosocial function, satisfaction, or self-rated health. Moreover, there was a twofold increase in mortality in the assessment group.

A 1990 study by Epstein and colleagues¹² compared geriatric assessment team consultations to both a consultant "second-opinion internist" and usual care in 600 elderly patients enrolled in a health maintenance organization (HMO). The assessment team made significantly more new diagnoses, medication changes, and psychosocial evaluations than did the other two groups. However, follow-up was limited to telephone calls, and there did not appear to be any cognitive function improvement at one year. This suggests that closer follow up and better targeting of those in need of continued care is necessary.

Stuck and colleagues⁸ performed a meta-analysis on the above four outpatient studies in an attempt to increase statistical power and possibly identify trends in outcomes more efficiently than could be determined in the smaller studies. However, unlike the results of the meta-analysis applied to inpatient teams, this analysis did not indicate significant differences in any of the measures, including mortality, physical and cognitive function, and living locations, between those patients who received geriatric assessment and those who did not.

A randomized trial conducted by Rubin and colleagues¹³ in 1992 examined the effects of geriatric assessment on Medicare reimbursement. Two hundred patients were randomized to receive usual inpatient and outpatient care or to receive geriatric evaluation and assessment in the hospital, continuing to outpatient care with the same team. Total charges to Medicare were measured. Results demonstrated that total charges and reimbursements were slightly higher for the control group, though not significantly. Additionally, there was a shift in expenditure in the assessment group from inpatient services to home health services.

A randomized, controlled clinical trial conducted by Toseland and colleagues,¹⁴ published in 1996, compared outpatient geriatric evaluation to usual care in 160 elderly VA patients who were considered "above-average users" of health care, meaning they had made 10 or more clinic visits in the year prior to randomization. Measures of health and function, psychosocial well-being, quality of health and social care, use of inpatient and outpatient services, and costs were assessed. Patients were evaluated at baseline and again at eight months. Those receiving geriatric assessment had decreased mortality, increased satisfaction, and better quality of health, but there was no decrease in health care use. In fact, patients in the geriatric evaluation group were seen at the clinic twice as often as those patients receiving usual care.

Despite this increased use of outpatient services, total costs did not differ between the two groups. The authors suggest that the initial similarity in cost may change over time. Study patients had more emergency room visits and more health care use, possibly due to careful assessment performed by the team and their success in identifying new problems. Had the study continued for a longer period of time, there may have been a reduction in costs as health and function improved. Furthermore, the team may have gained efficiency with experience, possibly reducing time spent per patient.

A 1994 study by Kravitz et al.¹⁵ looked at 152 patients recently discharged from a large California hospital. Assessment involved a home visit by a nurse practitioner and subsequent consultation on findings with an interdisciplinary team. Their findings and recommendations were sent to the primary care physician. The results identified new or worsening problems in 150 of 152 patients, with an average of 3.4 recommendations per patient. Thirty-three (22%) of the problems identified were medication-related; 21 of these were described as urgent and potentially life-threatening, involving prescribing errors, drug toxicity, and poor compliance. Ninety percent of all problems involved following instructions, including medication administration instructions. Forty-four percent of recommendations involved changing or altering medication regimens. While this was not a randomized, controlled trial, it involved outpatient assessment of the geriatric patient by an interdisciplinary team and revealed that medication-related issues are an important part of assessment.

Discussion

The trials described varied widely in the methods employed to obtain information, as well as in the outcomes measured. It is difficult to compare the trials and draw firm conclusions about the impact of geriatric assessment teams on health and cost outcomes. Overall, there is a trend toward improved health and functioning through diagnosis of new, treatable problems and through thorough assessment of psychosocial needs. All the authors, regardless of outcomes in their particular studies, support the use of geriatric assessment teams in the care of the elderly. Indeed, according to the survey by Epstein and colleagues,⁴ 69% of the assessment teams expected growth in their programs. Longitudinal studies should be conducted to determine the optimal structure, function, and target populations for geriatric assessment teams, and to determine whether these services improve health and quality of life.¹²

None of the studies reviewed included pharmacists as members of the team, though it is reasonable to assume that at least some of the teams consulted pharmacists. The three studies that measured medication changes or medication review revealed that geriatric assessment teams identified medication-related problems more often than was the case in the control groups receiving usual care.^7,12,15

Recently, abstracts have appeared describing the pharmacist's role in geriatric assessment teams.^16-19 Karnick and colleagues¹⁶ at the Center for Healthy Aging involved pharmacists in performing medication and diet histories. Wong et al.¹³ described the role of the clinical pharmacist as a drug information source on a geriatric team in a small community hospital. Patients referred to the pharmacist used fewer medications, experienced no adverse medication effects, and had a slightly reduced average length of stay.¹⁷

Kurose and Chen¹⁸ are conducting a study to evaluate the effects of pharmacist participation in a geriatric evaluation management program and to determine physician acceptance of the pharmacist as part of the team. Their study will also evaluate patient outcomes.

Use of geriatric assessment teams is a rapidly growing trend in the health care of the elderly. In general, patient satisfaction with geriatric assessment teams is high. There is widespread belief that interdisciplinary assessment is beneficial to the elderly individual with multiple health problems. While health care costs may not be reduced nor life prolonged, care for the elderly can be improved.

Today there is a trend toward cost-shifting and cost containment. Additional studies on the value of treating the geriatric population through an interdisciplinary approach are anticipated over the next few years. Research measuring the effect of pharmacist involvement on geriatric teams may become available. Hopefully, results will be positive. Pharmacists who work in institutions with geriatric assessment teams can rely on their skills and training in pharmaceutical care to become active team members, contributing to positive patient outcomes.

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