背景:衰弱干预措施如老年综合评估(CGA)可以为衰弱的老年人提供显著的益处。然而,将这种主动干预措施纳入初级保健仍然是一个挑战.我们开发了一种IT辅助CGA(i-CGA)流程,其中包括提前护理计划(ACP)。我们评估了,在老年养老院居民中,尤其是那些严重虚弱的人,i-CGA可以改善提前护理计划讨论的机会,并减少计划外住院。
方法:作为质量改进项目,我们逐步将i-CGA流程纳入老年护理院居民的常规初级保健中,并使用准实验方法来评估其临时影响。全科医生对居民的身体虚弱进行了评估。主动i-CGA完成,包括考虑传统的CGA域,开处方和ACP讨论。中期分析在1年进行:记录完成,对ACP的偏好和坚持,计划外入院,并比较了i-CGA组和对照组(常规护理)的死亡率,分别为i-CGA后1年或衰弱后诊断。使用卡方检验比较记录的ACP偏好和死亡地点。使用Mann-WhitneyU检验分析了计划外住院和卧床天数。使用Kaplan-Meier存活曲线估计存活率。
结果:一年后,i-CGA组有196名居民(重度虚弱111,57%);对照组有100名居民(重度虚弱56,56%).ACP记录在i-CGA组的100%,vs.对照组72%,p<0.0001。85%(94/111)严重虚弱的i-CGA居民如果严重不适,则不愿住院。对于那些严重虚弱的人,对照组(常规治疗)的平均非计划入院率从0.87(95%置信区间±0.25)/人年活期增加至2.05±1.37,而i-CGA组的平均非计划入院率从0.86±0.24降至0.68±0.37,p=0.22.两组都坚持首选的死亡地点,记录的地方。那些严重虚弱的人,55%(62/111)的i-CGA组死亡,vs.对照组的77%(43/56),p=0.0013。
结论:积极主动,基于社区的i-CGA可以改善养老院居民ACP偏好的记录,并可能减少计划外住院。在严重虚弱的居民中,在接受i-CGA的患者中发现死亡率降低.
BACKGROUND: Frailty interventions such as Comprehensive Geriatric Assessment (CGA) can provide significant benefits for older adults living with frailty. However, incorporating such proactive interventions into primary care remains a challenge. We developed an IT-assisted CGA (i-CGA) process, which includes advance care planning (ACP). We assessed if, in older care home residents, particularly those with severe frailty, i-CGA could improve access to advance care planning discussions and reduce unplanned hospitalisations.
METHODS: As a quality improvement project we progressively incorporated our i-CGA process into routine primary care for older care home residents, and used a quasi-experimental approach to assess its interim impact. Residents were assessed for frailty by General Practitioners. Proactive i-CGAs were completed, including consideration of traditional CGA domains, deprescribing and ACP discussions. Interim analysis was conducted at 1 year: documented completion, preferences and adherence to ACPs, unplanned hospital admissions, and mortality rates were compared for i-CGA and control (usual care) groups, 1-year post-i-CGA or post-frailty diagnosis respectively. Documented ACP preferences and place of death were compared using the Chi-Square Test. Unplanned hospital admissions and bed days were analysed using the Mann-Whitney U test. Survival was estimated using Kaplan-Meier survival curves.
RESULTS: At one year, the i-CGA group comprised 196 residents (severe frailty 111, 57%); the control group 100 (severe frailty 56, 56%). ACP was documented in 100% of the i-CGA group, vs. 72% of control group, p < 0.0001. 85% (94/111) of severely frail i-CGA residents preferred not to be hospitalised if they became acutely unwell. For those with severe frailty, mean unplanned admissions in the control (usual care) group increased from 0.87 (95% confidence interval ± 0.25) per person year alive to 2.05 ± 1.37, while in the i-CGA group they fell from 0.86 ± 0.24 to 0.68 ± 0.37, p = 0.22. Preferred place of death was largely adhered to in both groups, where documented. Of those with severe frailty, 55% (62/111) of the i-CGA group died, vs. 77% (43/56) of the control group, p = 0.0013.
CONCLUSIONS: Proactive, community-based i-CGA can improve documentation of care home residents\' ACP preferences, and may reduce unplanned hospital admissions. In severely frail residents, a mortality reduction was seen in those who received an i-CGA.