Department of General Practice, Univ Paris Est Creteil (UPEC), Health Faculty, 8 Rue du Général Sarrail, Creteil, 94010, France.
IMRB (CEpiA Group), Univ Paris Est Creteil, INSERM U955, Creteil, 94010, France.
BMC Med. 2024 Sep 27;22(1):414. doi: 10.1186/s12916-024-03613-7.
The benefits of comprehensive geriatric assessment (CGA) are well established for hospital care but less so for primary care. Our primary objective was to assess the effect of two multifaceted interventions based on a CGA adapted for primary care on a composite criterion combining all-cause mortality, emergency department visits, unplanned hospital admissions, and institutionalisation.
This open-label, pragmatic, three-arm, cluster-randomised controlled trial involved 39 general practices in France. It included 634 patients aged 70 years or over with chronic health conditions and/or an unplanned hospital admission in the past 3 months, between 05/2016 and 08/2018. Interventions were in arm 1: a systematic nurse-led CGA; arm 2: a GP-led CGA, at the GP's discretion; arm 3: standard care. The primary composite endpoint was assessed at 12 months. The secondary endpoints included: components of the composite endpoint, health-related quality of life (Duke Health Profile), functional status (Katz Activities of Daily Living Index) and medications (number) at 12 months. Pairwise comparisons between the experimental groups and the control were tested. The main analysis was performed on the intention-to-treat (ITT) population, after imputing missing information and adjusting for baseline imbalances by mixed effects regressions.
For the primary composite outcome, no statistically significant difference was found between arm 1 and the control (adjusted odds ratio [aOR] = 0.81 [95%CI 0.54-1.21], P = 0.31), whereas arm 2 and the control differed significantly (aOR = 0.60 [0.39-0.93], P = 0.022). A statistically lower risk of unplanned hospital admission in arm 2 vs control (aOR = 0.57 [0.36-0.92], P = 0.020)) was observed, while no statistically significant differences were found for the other components and between arm 1 and the control. None of the other secondary endpoints differed between arms.
Our study led in community-dwelling older patients with chronic conditions found no significant effect of a CGA adapted for primary care on mortality, functional independence and quality of life, but suggests that a GP-led CGA may reduce the risk of unplanned hospital admission. Our study demonstrates the feasibility of incorporating CGA into clinical practice and highlights its potential benefits when applied on a case-by-case basis, guided by the GPs who develop the resulting PCP.
NCT02664454.
综合老年评估（CGA）在医院护理中的益处已得到充分证实，但在初级保健中的益处则较少。我们的主要目标是评估基于适应初级保健的 CGA 的两种多方面干预措施对复合标准的影响，该标准结合了全因死亡率、急诊就诊、非计划性住院入院和机构化。
这是一项开放性、实用、三臂、群组随机对照试验，涉及法国的 39 家全科诊所。它包括 634 名年龄在 70 岁或以上、患有慢性健康状况和/或在过去 3 个月内有非计划性住院的患者，时间为 2016 年 5 月至 2018 年 8 月。干预措施在第 1 组：系统的护士主导的 CGA；第 2 组：由全科医生主导的 CGA，由全科医生决定；第 3 组：标准护理。主要复合终点在 12 个月时进行评估。次要终点包括：12 个月时的复合终点、健康相关生活质量（杜克健康状况问卷）、功能状态（Katz 日常生活活动指数）和药物（数量）。对实验组与对照组进行了两两比较。主要分析是在意向治疗（ITT）人群中进行的，在对缺失信息进行插补并通过混合效应回归调整基线不平衡后进行。
对于主要的复合结果，第 1 组与对照组之间没有统计学上的显著差异（调整后的优势比[aOR] = 0.81 [95%CI 0.54-1.21]，P = 0.31），而第 2 组与对照组之间有显著差异（aOR = 0.60 [0.39-0.93]，P = 0.022）。第 2 组与对照组相比，非计划性住院的风险显著降低（aOR = 0.57 [0.36-0.92]，P = 0.020），而其他组成部分和第 1 组与对照组之间没有统计学上的显著差异。其他次要终点在各组之间没有差异。
我们在社区居住的患有慢性疾病的老年患者中的研究发现，适应初级保健的 CGA 对死亡率、功能独立性和生活质量没有显著影响，但表明 GP 主导的 CGA 可能降低非计划性住院的风险。我们的研究证明了将 CGA 纳入临床实践的可行性，并强调了在临床医生指导下，根据患者情况逐例应用 CGA 的潜在益处。
