Geriatric consultation: is there a future?

The process of disciplined identification of common geriatric syndromes and risks in targeted individuals with careful prescription of preventives and treatments would seem, at face value, a logical response to a growing population of frail older patients in acute care hospitals. Yet, the evidence that such an approach produces measurable improvements in patient outcomes remains extremely limited, other than in the context of designated geriatric units. Hospital geriatric consultation services are now commonplace in most developed nations. Their role and function varies considerably, ranging from ‘triage’ services manned by individual geriatricians designed to identify patients suitable for transfer to post-acute services, through to well-resourced teams comprising geriatricians, specialist nurses and therapists who actively contribute to care provision in mixed ward settings. It is this latter, more intensive style of service that has been subject to the most intense evaluation. Although early studies showed promise in terms of improved patient outcomes [1], the majority found no differences when assessed against a range of clinical and administrative outcomes [2–6]. A meta-analysis of comprehensive geriatric assessment services identified no effects of this form of service [7]. The majority of studies have been conducted in North America. Arguably, in other jurisdictions where the background standard of geriatric assessment and the clinical and financial incentives for care might differ considerably, there may be different outcomes. The study of Kircher et al. [8], published in the current issue of this journal, presents the findings of a study conducted in Germany, where the authors report that geriatric consultation services have been established in the setting of a ‘social welfare healthcare system’. There might be sufficient contextual differences that geriatric consultation services could be more effective. The authors report that commencing in 1994, geriatric consultation services consisting typically of a geriatrician, nurse and social worker were established in a number of hospitals in Germany. The trial was conducted several years later, such that the five participating hospitals had already been exposed to the service for at least 3 years. This study, once again, failed to demonstrate any positive outcomes for patients allocated to the intervention group. A strength of the study was the inclusion of four ‘control’ hospitals, which apparently had no exposure to formal geriatric consultation. Patient outcomes in this group were similar to both the intervention and control groups in the intervention hospitals. This finding reduces the likelihood that contamination effects account for the lack of apparent impact of the intervention, which has been offered as a possible explanation for lack of impact in other similar studies [2, 3, 9]. It should be noted that the study outcome measures were recorded from 3 to 12 months after discharge from hospital. They included mortality, functional status and hospital and long-term institution utilisation rates. Short-term outcomes such as acute care length of stay, functional status and patient satisfaction at discharge, discharge to institutions and shortterm re-admission rates were not reported. Some studies, albeit involving more intensive inpatient interventions, have demonstrated short-term benefits that were not sustained into the medium term. For example, a large multi-centre study of veterans in the USA demonstrated improvements in functional status and patient well-being at hospital discharge that were not sustained into the medium term [10]. The reasons why these apparently appropriate service interventions have no measurable effect have been delineated by several earlier researchers: existing services are already at or near optimal performance; compliance with interventions is sub-optimal—particularly those that require the most intensive staffing resources; there is a type II trial design error—the study was inadequately powered; there are contamination effects; patient selection is incorrectly targeted; the study intervention is new and immature at the time of the trial; or that the intervention simply has no impact [2, 3, 9]. The German study has design attributes—it appeared adequately powered, the service was mature and a device for assessing contamination effects was included—that discount several of these explanations. However, this service was provided in the context of a previous history of availability of the service and thus the possibility of an existing high standard of care cannot be excluded. The failure to measure short-term outcomes raises the possibility that some real benefits were not identified. Before concluding that geriatric consultation services lack efficacy, we must ensure that there are no worthwhile benefits that have yet to be identified. Winograd suggested that there is a need for further research that targets specific recommendations with more intense clinical responses [5]. This is based on the idea that the interventions most likely to influence outcomes are the most resource intensive and were least likely to be implemented in previous trials because of staffing limitations. An excellent example is the very specific strategy devised by Inouye to reduce the risk of developing delirium [11]. More research is needed to explore this concept. How then, are we to advise health administrators on the provision of acute hospital geriatric services? First, in the face of good evidence of efficacy of designated geriatric units,