Fletcher Astrid E, Price Gill M, Ng Edmond S W, Stirling Susan L, Bulpitt Christopher J, Breeze Elizabeth, Nunes Maria, Jones Dee A, Latif Amina, Fasey Nicola M, Vickers Madge R, Tulloch Alistair J
Centre for Ageing and Public Health, London School of Hygiene and Tropical Medicine, London, UK.
Lancet. 2004;364(9446):1667-77. doi: 10.1016/S0140-6736(04)17353-4.
The benefit of multidimensional assessment and management of older people remains controversial. Most trials have been too small to produce adequate evidence to inform policy. We aimed to measure the effects of different approaches to assessment and management of older people.
We undertook a cluster-randomised factorial trial in 106 general practices (43219 eligible patients aged 75 years and older, 78% participation), comparing (1) universal versus targeted assessment and (2) subsequent management by hospital outpatient geriatric team versus the primary-care team. All participants received a brief multidimensional assessment followed by a nurse-led in-depth assessment in the universal group, whereas in the targeted group the in-depth assessment was offered only to those with problems established at the brief assessment. Referrals to the randomised team (geriatric management or primary care), other medical or social services, health-care workers, or agencies, and emergency referrals to the general practitioner were based on a standard protocol at the in-depth assessment. The primary endpoints were mortality, admissions to hospital and institution, and quality of life. Analysis was by intention to treat and per protocol. This trial has been assigned the International Standardised Randomised Controlled Trial Number ISRCTN23494848.
Mortality and hospital or institutional admissions did not differ between groups. During 3 years' follow-up, significant improvements in quality of life resulted from universal versus targeted assessment in terms of homecare, and from management by geriatric team versus primary-care team, in terms of mobility, social interaction, and morale. However, only the result for social interaction was consistent with a small but important effect.
The different forms of multidimensional assessment offered almost no differences in patient outcome.
对老年人进行多维度评估和管理的益处仍存在争议。大多数试验规模太小，无法产生足够的证据为政策提供依据。我们旨在衡量不同的老年人评估和管理方法的效果。
我们在106家普通诊所进行了一项整群随机析因试验（43219名75岁及以上符合条件的患者，参与率为78%），比较（1）全面评估与针对性评估，以及（2）随后由医院老年门诊团队管理与由初级保健团队管理。所有参与者都接受了简短的多维度评估，随后在全面评估组中由护士主导进行深入评估，而在针对性评估组中，仅对在简短评估中发现有问题的人进行深入评估。根据深入评估时的标准方案，将患者转诊至随机分组的团队（老年管理或初级保健）、其他医疗或社会服务机构、医护人员或机构，以及紧急转诊至全科医生处。主要终点为死亡率、住院和入住机构情况以及生活质量。分析采用意向性分析和符合方案分析。该试验已被分配国际标准化随机对照试验编号ISRCTN23494848。
两组之间的死亡率、住院或入住机构情况没有差异。在3年的随访期间，在家庭护理方面，全面评估与针对性评估相比，生活质量有显著改善；在行动能力、社交互动和士气方面，老年团队管理与初级保健团队管理相比，生活质量有显著改善。然而，只有社交互动方面的结果与一个虽小但重要的效应一致。
不同形式的多维度评估在患者结局方面几乎没有差异。
