The impact of a comprehensive multi-dimensional geriatric assessment programme on duration of stay in a French acute medical ward.
In France, as in other Western countries, the proportion of elderly persons in the general population has been steadily increasing, rising from 13.9% of the population over 65 in 1982 (7 528 708 persons) to 14.7% in 1990 (8 347 959 persons) and estimated to increase to 15.7% (9 113 321 persons) by the year 2000. It is also well documented that the health of persons over 65 is significantly poorer than that of the general population with an especially high prevalence of sensory defects, locomotor difficulties, arterial hypertension, cardiac illness and cognitive deterioration (1)(2)(3). Owing to the cumulative effects of illnesses over a lifetime, the elderly person becomes more fragile and vulnerable with multiple pathologies. Not surprisingly the rate of hospitalization in elderly populations is high; in the Paris region for example, persons over 65 constitute 23.4% of patients and 33% of days spent in hospital although representing only 11.1% of the population (4).
In addition to problems of health and an increasing risk of hospitalization, the elderly population is frequently exposed to financial hardship and poor living conditions. Data from the national census of 1982 show, for example, that, in the Paris region 11.4% of homes occupied by elderly persons did not have hot water, 12.1% did not have a toilet and 45.5% of persons lived alone. These factors, in conjunction with the increased prevalence of disability amongst older people, mean that the discharge of an elderly person from acute hospital care is often not the happy return to the community experienced by younger persons, but rather a point of crisis. Illness and hospitalization with their adverse effects on both physical and mental strength serve further to reduce the elderly person's capacity to deal with inappropriate living conditions. Social services are rallied at the moment of intended discharge to confront this unanticipated crisis situation resulting in the prolongation of stay of the elderly person for non-medical reasons. A study conducted in Aquitaine in 1983 (5) has shown that only one third of persons over 75 admitted to acute care were able to return home and that 10% of acute-care hospital days were due to prolongation of care for non-medical reasons. On the other hand, in a great number of cases, there is no discussion between the medical staff and the elderly patient to prepare for discharge (6).
This situation is not only costly in that acute hospital beds are used as temporary sheltered accommodation, but the situation of 'crisis management' which is thereby engendered is stressful both for hospital personnel and care-givers. Moreover the outcome, in terms of longerterm housing for the elderly persons, risks being inappropriate due to the rapidity with which a solution must be sought.
The present study aimed to develop and evaluate an intervention strategy designed to ameliorate the management of this potential crisis situation. The principal working hypothesis is that the introduction of multidimensional-geriatric assessment (MDGA) in the first three days of admission will permit the prediction of individual medico-social needs at discharge, allow recommendations for possible post-discharge placement and thus reduce the extent to which acute-ward stay is extended for non-medical reasons.
The study was carried out at the Bichat Hospital, Paris, whose catchment area has a high proportion of elderly persons (19.0%) in comparison with the national average (13.9%). This group is also at high risk of post-admission difficulties in community re-integration having particularly poor living conditions (21.5% without toilets and 19.5% without hot water), insufficient domiciliary aid services and poor social network. The study took place in two internal medicine wards over a period of 7 months. Two groups were constituted from amongst all persons over 65 years hospitalized for the first time in the ward; an experimental group of 52 persons who were the subject of the post-admission geriatric assessment procedure and a control group of 54 persons. It was calculated that in order to demonstrate a 20% reduction in duration of stay, taking into account average length of stay in the ward, at least 40 subjects would be required in each group. Thus although the sample is small, statistically it should be sufficiently large to show any significant differences resulting from the experimental condition.
A multi-dimensional geriatric assessment instrument (MDGA) was developed for the purpose of this study consisting of three parts: living conditions, disabilities in relation to activities of daily living and measures of adequacy of the intervention procedure. An English translation of the MDGA is given in the Appendix.
Part I (living conditions) provides information relating to marital status, place of residence, accessibility of residence, sanitation, heating, telephone, support network and present use of domiciliary aid. This first part derives from questionnaires already used in studies of living conditions and health states of elderly people conducted in several French regions (7).
Part II (disabilities) consists of a French translation of the Rapid Disability Screening Scale RDRS--2 developed and validated by Linn and Linn (8). This 18-item questionnaire was designed specifically for the improved channelling of individuals within the health and social services system. Each item is scored one to four giving a total score of between 18 (no disability) and 72 (total disability in all areas).
Part III (evaluation of intervention procedures) consists of information relating to duration of stay, duration of prolongation of stay due to non-medical reasons, recourse to a social worker, the type of discharge desired and the actual outcome at discharge. The existence and duration of a medically nonjustifiable extension of stay was evaluated according to implicit criteria by the physician responsible for the patient. The interviewer (B.L.) asked the physician on what date the patient should have been discharged given his or her health status.
In addition, information and recommendations concerning the long-term residency options presently available according to the individual's health status and the places available in the area were obtained from a computerized consultation service available for public use through the telephone network. This service, known as Philomene, provides information kept up to date by the directors of all available social services and housing alternatives. The programme provides a series of recommendations which best meet individual needs and information on waiting lists in appropriate institutions. The utility and interrater reliability of the programme have been demonstrated by De Butter (9).
The MDGA schedule and the computer consultation regarding care options are carried out within the first three days of admission to the acute ward for each subject of the experimental group. For this group, the results are transmitted to the responsible medical officer. As the average length of stay in internal medicine is around 3 weeks for persons over 65, the medical personnel have time, under normal circumstances, to plan discharge well beforehand.
The socio-demographic characteristics of the sample are given in Table I. Over half the sample was found to be widowed and no differences were found between the control and experimental group. The living conditions and levels of dependency for both the experimental and control groups were, as expected, exceptionally poor and generally representative of the entire catchment area (see Table II). Despite living in an urban setting, 12% were found not to have a toilet in their own home and 12% were without hot water. Half of the population have an income so low that they are not required to pay taxes. Apart from a slightly greater number of persons in the control group being required to climb stairs in order to reach their homes, there were no differences between the elderly persons in the two groups with regard to level of dependency. Overall the two groups show a high proportion of disability.
Control group Experimental group n % n % p Men 27 50 29 56 Women 27 50 23 44 NS Age (years) mean (SD) 54 81 (8) 52 81 (8) NS Marital status: Married 17 32 18 36 Widowed 26 48 27 54 Single 11 20 5 10 NS Emergency admission 27 50 29 56 NS
[TABULAR DATA OMITTED]
A comparison of outcome after discharge for the two groups is given in Table III. Although the percentage increase in length of stay without medical justification is reduced from 28% in the control group to 10% in the experimental group, which is equal to a reduction of an average of four days of unjustified prolongation of stay per patient, there is only a trend toward a diminution of the total length of stay in the experimental group. No difference was found in the delay for receiving assistance from the social worker.
[TABULAR DATA OMITTED]
This study has not shown the hoped for effect of the proposed procedure on the duration of hospitalization of elderly persons. However, a significant effect was observed regarding the number and duration of the extensions of stay without medical justification. This impact on prolongation of stay for non-medical reasons may be achieved with the provision of a very small amount of information. The important point is that information concerning the medical, social, financial and dependency status of the individual are centred at one point, the medical officer, instead of being dispersed at the last minute through a variety of hospital and community medical and social services. Providing this information shortly after admission appears to lead to the avoidance of a crisis situation at discharge. The extensive literature on 'crisis management' suggests that such situations tend to be costly in terms of both financial and human resources. The outcome is also likely to be less satisfactory than for normal 'long-term social management'. The use of the MDGA appears to minimize the risk of 'social crisis'.
The use of comprehensive geriatric assessment techniques to predict discharge needs has been recommended by a number of authors (10)(11)(12). While Applegate et al. (13) concluded that their effectiveness is highly variable, Hogan et al. (14) noted that a significant impact is more likely when such services are directed at high-risk groups and the members of the evaluating team are involved in care. The present study strongly supports Hogan's hypothesis, showing that elderly persons admitted to short-term geriatric care from a catchment area with a high prevalence of disabilities, strained social services and generally very poor living conditions have an average reduction of 4 days in the medically unjustifiable length of their stay due to early sensitization of medical staff to the person's sociomedical situation.
A shortcoming of the present study is the lack of evaluation of the discharge process. The effectiveness was not evaluated with regard to discharge location, either at initial discharge or subsequently, or to rates of rehospitalization.
Although the procedure proved to be effective on unjustified prolongation of stay, it was not subsequently integrated into the routine functioning of the ward. Further reflection is clearly required in order to understand why this procedure was not easily adaptable to everyday clinical practice. Perhaps an alternative strategy is required. The role of the social worker in the French teaching hospitals, in this respect, should be explored. Further collaboration between clinicians and social workers should be considered. The standardized procedure (MDGA) presented here could well be completed jointly so that discharge outcome is a result of both clinical and social evaluation.
The present study describes the utilization, in a short-stay medical ward, of a multi-dimensional geriatric assessment system summarizing the socio-medical status of the individual. The provision of such information in the days following admission appears significantly to reduce the prolongation of stay due to non-medical reasons but without a statistically significant impact on the length of stay. It is suggested that institutions introduce longer-term evaluation studies to check the long-term consequences of decisions made at discharge.
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|Author:||Ledesert, B.; Lombrail, P.; Yeni, P.; Carbon, C.; Brodin, M.|
|Publication:||Age and Ageing|
|Date:||May 1, 1994|
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