Comprehensive geriatric assessment for older people admitted to a surgical service

Gilgamesh Eamer; Amir Taheri; Sidian S Chen; Quinn Daviduck; Thane Chambers; Xinzhe Shi; Rachel G Khadaroo

doi:10.1002/14651858.CD012485.pub2

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Geriatric care versus control, Outcome 1 Mortality.

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Analysis 1.2

Comparison 1 Geriatric care versus control, Outcome 2 Discharge to an increased level of care.

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Analysis 1.3

Comparison 1 Geriatric care versus control, Outcome 3 Length of stay.

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Analysis 1.4

Comparison 1 Geriatric care versus control, Outcome 4 Re‐admission.

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Analysis 1.5

Comparison 1 Geriatric care versus control, Outcome 5 Major complication.

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Analysis 1.6

Comparison 1 Geriatric care versus control, Outcome 6 Major complication ‐ delirium.

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Summary of findings for the main comparison. Comprehensive geriatric assessment for older people admitted to a surgical service

Comprehensive geriatric assessment for older people admitted to a surgical service
Patient or population: Improving outcomes in older adult people admitted to a surgical service. Setting: Acute hospital or rehabilitation hospital following acute admission; Canada, Netherlands, Norway, UK, USA, Spain, and Sweden. Intervention: Comprehensive geriatric assessment. Comparison: Control.
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Outcomes	Risk with control	Risk with geriatric care	Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Mortality	214 per 1000	182 per 1000 (145 to 225)	RR 0.85 (0.68 to 1.05)	1316 (5 randomised trials)	⊕⊕⊕◯ ¹ MODERATE	Hip fracture studies.
Discharge to an increased level of care	247 per 1000	176 per 1000 (136 to 227)	RR 0.71 (0.55 to 0.92)	941 (5 randomised trials)	⊕⊕⊕⊕ HIGH	Hip fracture studies.
Length of stay	Meta‐analysis was not performed due to high heterogeneity (Analysis 1.3)	MD in studies ranged from ‐12.8 days to 8.3 days	‐	841 (4 randomised trials)	⊕⊕⊕⊝ MODERATE ²	Hip fracture studies ‐ length of stay until final discharge from hospital (including rehabilitation hospital). Meta‐analysis was not retained due to high heterogeneity (I² = 88%, P < 0.00001).
Re‐admission	316 per 1000	316 per 1000 (240 to 418)	RR 1.00 (0.76 to 1.32)	741 (3 randomised trials)	⊕⊕⊕⊝ MODERATE ¹	All studies included; removing elective surgical oncology study doesn't change effect.
Total cost	The mean total cost was EUR 59,486	MD EUR 5154 lower (13,288 lower to 2980 higher)		397 (1 randomised trials)	⊕⊕⊕⊝ MODERATE ³	1 study reported cost.
Major complication	Meta‐analysis was not performed due to high heterogeneity (Analysis 1.5)	Two studies reported this outcome with RRs of 0.74 and 1.16		579 (2 randomised trials)	⊕⊕⊝⊝ LOW ^{1 2}	Hempenius 2013 defined major as 2 or more complications. Vidán 2005 defined major as delirium, congestive heart failure, pneumonia, DVT, PE, pressure ulcer, arrhythmia and myocardial infarction. Meta‐analysis was not retained due to high heterogeneity (I² = 77%, P = 0.04).
Major complication ‐ delirium	327 per 1000	245 per 1000 (196 to 307)	RR 0.75 (0.60 to 0.94)	705 (3 randomised trials)	⊕⊕⊝⊝ LOW^{1 4}	Delirium assessed by Delirium Observation Scale (Hempenius 2013) or confusion assessment method (Marcantonio 2001; Vidán 2005)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio; OR: Odds ratio;
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ We downgraded due to imprecision because there were wide confidence intervals that include both no effect and a high risk of benefit or harm. ² We downgraded due to inconsistency because there was significant variability among studies. ³ We downgraded due to other considerations because costing was calculated in an imprecise manner (costs are presented as the total cost over one year, however the admission cost did not include rehabilitation hospital costs despite the authors identifying a higher proportion of control patients being transferred to rehabilitation centres before discharge). ⁴ We downgraded due to the high risk of bias.

Summary of findings for the main comparison. Comprehensive geriatric assessment for older people admitted to a surgical service

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Comparison 1. Geriatric care versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality Show forest plot	5	1316	Risk Ratio (IV, Random, 95% CI)	0.85 [0.68, 1.05]

1.1 4 to 6 months	2	476	Risk Ratio (IV, Random, 95% CI)	0.74 [0.46, 1.20]
1.2 1 year	3	840	Risk Ratio (IV, Random, 95% CI)	0.87 [0.69, 1.11]
2 Discharge to an increased level of care Show forest plot	5	941	Risk Ratio (IV, Random, 95% CI)	0.71 [0.55, 0.92]

2.1 Discharge	1	108	Risk Ratio (IV, Random, 95% CI)	0.31 [0.12, 0.79]
2.2 4 to 6 months	2	344	Risk Ratio (IV, Random, 95% CI)	0.81 [0.54, 1.21]
2.3 1 year	2	489	Risk Ratio (IV, Random, 95% CI)	0.73 [0.52, 1.03]
3 Length of stay Show forest plot	5		Mean Difference (IV, Random, 95% CI)	Totals not selected

3.1 Acute hospital discharge	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3.2 Discharge	4		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 Re‐admission Show forest plot	3	741	Risk Ratio (IV, Random, 95% CI)	1.00 [0.76, 1.32]

4.1 1 to 3 months	1	225	Risk Ratio (IV, Random, 95% CI)	1.25 [0.74, 2.09]
4.2 1 year	2	516	Risk Ratio (IV, Random, 95% CI)	0.95 [0.67, 1.33]
5 Major complication Show forest plot	2		Risk Ratio (IV, Fixed, 95% CI)	Totals not selected

5.1 Discharge	2		Risk Ratio (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Major complication ‐ delirium Show forest plot	3		Risk Ratio (IV, Random, 95% CI)	Subtotals only

6.1 Discharge	3	705	Risk Ratio (IV, Random, 95% CI)	0.75 [0.60, 0.94]

Comparison 1. Geriatric care versus control

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