Population-based multidimensional assessment of older people in UK general practice: a cluster-randomised factorial trial

Summary

Background

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.

Methods

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.

Findings

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.

Interpretation

The different forms of multidimensional assessment offered almost no differences in patient outcome.

Introduction

The benefits of multidimensional assessment of older people in the community setting are controversial. Although improved functional measures and reductions in mortality and hospital and institutional care have been reported in trials in North America, the UK, and other European settings,1, 2, 3, 4, 5 the findings have not been consistent nor have they had sufficient power to establish any benefits with the degree of precision and certainty necessary for policy decisions. Nevertheless, in 1990, the UK Department of Health introduced a contract of service for general practitioners (GPs), which required them to offer an annual multidimensional assessment to patients aged 75 years and older.⁶ Although the contract specified the broad areas for assessment, it gave little guidance on the method, level, and nature of assessment.

Concerns about the feasibility of offering assessment to all elderly patients led to suggestions to focus on those with the highest levels of morbidity identified through a two-stage targeted approach,7, 8, 9, 10 but the relative costs and benefits of assessing all patients versus a targeted approach have not been measured. Models of problem management identified through the assessment process also need to be appraised. In studies mainly in North America,11, 12, 13, 14, 15 multidisciplinary outpatient geriatric assessment and management seems to offer advantages in functional status, psychological wellbeing, and social activity, but no benefit for mortality or admissions to institutional care. The benefits of a hospital-based geriatric assessment team as an integrated component of multidimensional assessment, compared with the usual model of primary care, have yet to be established. We undertook a trial in the setting of general practice in the UK to measure the effects of different approaches to assessment and management of old people.