International landscape of guidelines for perioperative frailty assessment and barriers to clinical translation.

As a population ages, performing comprehensive geriatric assessment (CGA) is necessary to help clinicians manage older adults' conditions and to prevent or delay complications. CGA is now known as the best method by which to improve care outcomes and quality of life in older adults, and it requires a multidisciplinary approach. The aim of CGA is to identify older adults' needs, develop individual care plans, and improve care outcomes.1 Care outcomes are the results of treatment. They're also a key performance indicator for hospitals. The most common negative key performance indicators related to older adults are a long hospital stay, dying in the hospital, and unplanned readmission.2 The implementation of CGA may help control the care outcomes of older adults, as one of its main functions is to improve these outcomes. However, previous studies have shown inconsistent results related to CGA—although some have indicated that CGA improves care outcomes, others have found that CGA can worsen them. Specifically, many studies have reported that the implementation of the CGA model can reduce lengths of stay, readmission rates, and in-hospital mortality among hospitalized older adults, especially in the geriatric ward.3-6 However, others have reported these three care outcome parameters increased following the implementation of the CGA model.4-7 The reason for these inconsistencies requires further investigation. For example, it's possible that the method of CGA implementation varied among studies. As such, investigation is needed into how CGA is being conducted, especially the completeness of the CGA tool used; this is integral to achieving a comprehensive diagnosis and identifying appropriate interventions. Accordingly, this study was conducted to evaluate the completeness of the CGA tool and its relationship to care outcomes among older adults—especially readmission rates, lengths of hospital stay, and in-hospital mortality. Methods Investigators retrospectively evaluated older adults' medical records in one of the first—and largest—referral hospitals in Indonesia. To evaluate readmission rates, patients' medical records were reviewed for 30 days after discharge from the hospital. Included in this study was a sample of 222 hospitalized adults age 60 years or older who had a minimum of two diseases according to medical diagnosis. Older adults who were admitted or transferred to the ICU and those who were hospitalized for less than 24 hours were excluded from the study. The selection technique applied was stratified random sampling. Multiple logistic regression analyses were used to look for the predictor influence of the dependent variables of 30-day readmission and in-hospital death and examine the predictors of length of stay. Geriatric medical teams for participants performed various assessments to evaluate the completeness of the CGA. The researchers created this completeness evaluation, which comprised 4 domains (physical health, functional status, psychological health, and socioenvironmental status) broken into 21 items. The total completeness score ranged from 0 to 21. The data were then converted into percentages to facilitate analysis and evaluation. This evaluation utilized the observational checklist instrument, which had been tested for validity and reliability. Researchers conducted a pilot study to test this instrument and found it to be valid and reliable. It received a score of 0.89 using the content validity index (CVI). This CVI was reviewed by eight experts from Indonesia and Taiwan, including a geriatrician, a geriatric nurse, and gerontological nursing lecturers. The reliability test used an internal consistency and interrater reliability test. The internal consistency test analyzed by Kuder-Richardson Formula 20 with a result of 0.73 means the instrument is reasonably reliable in producing a consistent score. Results Completeness of CGA The overall average completeness of the CGA performed on the included patients was 68.19% (SD, 7.85). The CGA was more likely to be fully complete when conducted on the geriatric ward (71.99%; SD, 8.54) than on the nongeriatric ward (64.52%; SD, 4.85), with a significant difference (t = −7.99; P = .000). Table 1 presents a description of the CGA's completeness in terms of the total score and the score for each of the four evaluated domains. Table 1: - Description of the completeness of CGA (N = 222) Variables Mean ± SD Median (Range) 95% CI Completeness of CGA 68.19 ± 7.85 66.67 (52.38-85.71) 67.15-69.23 Physical health 84.73 ± 5.39 88.89 (77.78-88.89) 84.02-85.44 Functional status 39.34 ± 12.84 33.33 (33.33-66.67) 37.64-41.04 Psychological health 12.01 ± 25.68 00.00 (00.00-66.67) 8.62-15.41 Socioenvironmental status 86.04 ± 10.16 83.33 (50.00-100) 84.69-87.38 Looking at each domain in greater detail, only socioenvironmental status was completely evaluated by the medical care team. In each of the three other domains, at least one item wasn't examined at all. A detailed description of each item evaluated within the four domains is given below, and the data are presented in Table 2. Table 2: - Data distribution of the completeness of CGA for each item by ward type (N = 222) Type of ward Domain (mean ± SD)/Item, n (%) Nongeriatric (n = 113) Geriatric (n = 109) Total X2/U P Physical health 83.19 ± 5.58 86.34 ± 4.69 84.73 ± 5.39 4410 .000∗ Chief complaint 113 (100) 109 (100) 222 (100) - - Medical history 113 (100) 109 (100) 222 (100) - - Healthy behavior history 55 (48.7) 84 (77.1) 139 (62.6) 19.1 .000∗ Physical assessment 113 (100) 109 (100) 222 (100) - - Multimorbidity 113 (100) 109 (100) 222 (100) - - Polypharmacy 113 (100) 109 (100) 222 (100) - - Nutrition status 113 (100) 109 (100) 222 (100) - - Balance 0 0 0 - - Risk of fall 113 (100) 109 (100) 222 (100) - - Functional status 34.22 ± 5.38 44.65 ± 15.86 39.34 ± 12.84 4231 .000∗ Activity of daily living 113 (100) 109 (100) 222 (100) - - Instrumental of activity daily living 3 (2.7) 37 (33.9) 40 (18) 36.77 .000∗ Mobility 0 0 0 - - Psychological health 1.77 ± 10.77 22.63 ± 31.71 12.01 ± 25.68 4231 .000Re Cognition 3 (2.7) 37 (33.9) 40 (18) 36.77 .000∗ Delirium 0 0 0 - - Mood 3 (2.7) 37 (33.9) 40 (18) 36.77 .000∗ Socioenvironmental status 83.33 ± 9.71 88.84 ± 9.9 86.04 ± 10.16 4512.5 .000∗ Marital status 113 (100) 109 (100) 222 (100) - - Guardian 113 (100) 109 (100) 222 (100) - - Caregiver 106 (93.8) 108 (99.1) 214 (96.4) 4.45 .066 Environmental support 108 (95.6) 108 (99.1) 216 (97.3) 2.59 .213 Financial situation 109 (96.5) 104 (95) 213 (95.9) 0.16 .745 Social activity 16 (14.2) 43 (39.4) 59 (26.6) 18.18 .000∗ ∗Correlation is significant at the alpha level (.05). Care outcomes As shown in Table 3, compared with the older adults on the nongeriatric ward, those on the geriatric ward experienced a lower rate of readmission (4.6% versus 8%) but a higher rate of in-hospital death (13.8% versus 2.7%). In addition, the older adults hospitalized on the geriatric ward stayed in the hospital significantly longer than did the older adults on the nongeriatric ward (U = 4854; P = .006). Table 3: - Care outcomes in relation to ward type Type of ward Care outcomes Total Geriatric Nongeriatric X2/U Score P 30-day readmission, n (%) 0.58 .448 Yes 14 (6.3) 5 (4.6) 9 (8) No 208 (93.7) 104 (95.4) 104 (92) In-hospital death, n (%) 7.76 .005∗ Yes 18 (8.1) 15 (13.8) 3 (2.7) No 204 (91.9) 94 (91.9) 110 (97.3) Length of stay, median (range) 8 (2-62) 10 (2-34) 7 (2-62) 4854 .006∗ ∗Correlation is significant at the alpha level (.05). Completeness of CGA in relation to care outcomes The length of hospital stay care outcome showed different results from the other two outcomes as shown in Table 4. In general, there was a significant relationship between the completeness of the CGA and the length of stay (r = 0.15; P = .028). When evaluating by ward type, a significant relationship between the two parameters was observed for patients on the geriatric ward (r = 0.19; P = .041) but not for those on the nongeriatric ward (r = −0.081; P = .393). In other words, the length of hospital stay was significantly correlated with the completeness of the CGA for the total sample and for the geriatric ward. Both correlations were positive and moderate, meaning that the more complete the CGA was, the longer the hospital stay. Table 4: - Completeness of CGA in relation to care outcomes Completeness of CGA Care Outcomes Total (n = 222) Geriatric (n = 109) Nongeriatric (n = 113) Mean ± SD t/r (P) Mean ± SD t/r (P) Mean ± SD t/r (P) 30-day readmission 1.13 (.272) 0.92 (.361) −0.70 (.483) Yes 66.67 ± 4.94 68.57 ± 7.22 65.61 ± 3.18 No 68.29 ± 8.00 72.16 ± 8.59 64.42 ± 4.97 In-hospital death −0.33 (.739) 0.89 (.372) 0.95 (.346) Yes 68.78 ± 8.68 70.16 ± 8.72 61.90 ± 4.77 No 68.14 ± 7.79 72.29 ± 8.52 64.59 ± 4.85 Length of stay 0.15 (.028)∗ 0.19 (.041)∗ −0.08 (.393) ∗Correlation is significant at the alpha level (.05). Correlation between completeness of CGA and care outcomes, controlling for other variables The multiple logistic regression analysis found no significant results related to readmission. Only the type of ward had a significant influence on in-hospital death (odds ratio [OR] = 7.28; P = .004). This indicates that older adults hospitalized on the geriatric ward had a probability of death that was seven times higher than those hospitalized on the nongeriatric ward. Further, analysis indicated that the only predictor of length of stay was comorbidity. However, upon examining this by ward type, the completeness of the CGA had a significant impact on and predicted length of stay only for patients on the geriatric ward (B = 0.02; t = 2.08; P < .05). This result indicates that every change by one unit in the completeness of the CGA increased the length of stay by 2 days. Study authors hypothesize that when a CGA is more complete, more problems are identified, necessitating further medical treatment; accordingly, providing a comprehensive intervention to manage all the identified problems might result in a longer length of stay.6,8 Discussion Completeness of CGA The completeness of the CGA was defined as how comprehensively the geriatric medical team assessed participants during hospitalization. The analyses conducted in this study indicated that, on average, the reviewed CGAs were only slightly more than 50% complete. Unfortunately, this result can't be compared with other studies because no previous studies have evaluated CGA completeness. Moreover, this result doesn't correspond to the concept of CGA, which is the primary recommended intervention for geriatric wards.4 Although policy requirements are in place regarding the use of CGA as part of the provision of geriatric services, the percentage of CGA completeness on the geriatric ward alone was only about 72%. A comprehensive CGA is vital to establish diagnoses and ensure that the interventions provided are appropriate and in accordance with each patient's needs. The results also showed that CGA wasn't optimally implemented in the hospital setting, as some items were frequently skipped. As such, other medical teams—especially nurses—must contribute to the CGA, as they spend a significant amount of time with patients; their input could reduce missing data, making the CGA more comprehensive and complete, enhancing care outcomes for older adults. Care outcomes 30-day readmission. Based on a review of all the older patients who were readmitted within 30 days after discharge from the hospital, individuals on the nongeriatric ward had twice as many readmissions as did those on the geriatric ward. Previous related studies found that patients who had been treated in the CGA group had fewer readmissions.3,5 In terms of the relationship between the completeness of the CGA and readmission, the total sample score of the average number of older adults who were readmitted was lower than that of patients who didn't require readmission. On the nongeriatric ward, patients who were readmitted had a higher CGA completeness score than those who weren't readmitted. Even though this difference wasn't statistically significant, it's possible that on the geriatric ward, the more complete a CGA is, the more likely it is that a readmission event can be avoided. This result could be explained by the fact that, on the geriatric ward, a predefined CGA intervention package was implemented that included multidimensional assessment, multidisciplinary specialty expertise, geriatric meetings, care plans focused on patient-centered goals based on CGA results, the implementation of care plans by geriatric nurse specialists, and a continuous review of progress and care planning.4 In-hospital death. The rate of in-hospital death on the geriatric ward was about five times greater than that on the nongeriatric ward. Considering that the CGA was applied on the geriatric ward in the hospital analyzed in this study, this result was quite surprising. Nevertheless, the characteristics of patients on the geriatric ward—for example, being older and having more diseases—could be the reason why the mortality was higher. These results are also in line with a previous study, which showed that more older adults died on the geriatric ward than on the general ward.7 The relationship between the in-hospital mortality and the completeness of the CGA wasn't statistically significant. However, the mean CGA completeness score for older adults who didn't die in the hospital tended to be higher than that for patients who did, for both wards. This result is consistent with previous research, which stated that CGA can reduce mortality among hospitalized older adults.3,4,6 Length of stay. Length of hospital stay wasn't significantly related to age but was significantly related to comorbidities and ward type. The more illnesses a patient had, the longer their hospital stay. Further, older adults on the geriatric ward with more illnesses also stayed in the hospital longer than did those on the nongeriatric ward. This aligns with a previous study indicating that prolonged hospital stays often occur in older adults because of the higher incidence of complications, such as multimorbidity.9 The completeness of the CGA had a significant relationship with length of stay. For the total sample and on the geriatric ward, the relationship was positive and moderate or typical. This means that the more complete the CGA was, the longer the patient stayed in the hospital. This positive relationship is supported by previous studies.5-7 Limitations This study only evaluated the assessment part of the CGA, although there are three steps in the CGA process and six key features of CGA. The assessment part is the first stage. For effective implementation to improve care outcomes, the entire process and all of the key features need to be completed, although this wasn't the subject of the present study. Second, this study excluded older adults who were transferred to the ICU, High Care Unit, and Intensive Coronory Care Unit while they were hospitalized. This exclusion criterion was designed to control the condition of the older adults in both wards, so they were similar in acuity. However, this means the results underestimate the possibility that the older adults could die in the hospital, thus influencing mortality data. Third, the data for readmission were measured only by counting the rate of participants readmitted to the same hospital. Investigators didn't collect the reason for the readmission nor account for the possibility of patients being readmitted to another hospital. This could underestimate the readmission rate of the older patients. Fourth, the independent variables were few: age, comorbidity, ward type, and the completeness of CGA. The complex care outcomes of older adults might be influenced by many other factors, such as healthcare and patient factors, that warrant further investigation. Finally, these study results can only be generalized to similar settings and populations. Further revision of the 21-item evaluation for the CGA should be investigated in future studies. Implications for nurse leaders Nurse leaders, especially in geriatric settings, should understand that the CGA may not be optimally implemented in a hospital setting, and note which items aren't frequently assessed. The domains of functional status and psychological health in particular had a low completion rate. Although the entire team is responsible for addressing this concern, the nurse leader must identify and educate those who don't regularly complete full and complete evaluations. Involving nurses in the completion of the CGA would lead to more comprehensive assessments that ultimately improve care outcomes for older adults. These authors also challenge nurse leaders to get involved with policymaking to provide regulations for all medical teams that treat older adults, particularly in relation to geriatric assessments including the CGA. Getting to 100% The average CGA completeness score in this study was 68.19%, and the completeness rate in the geriatric ward was significantly higher than in the nongeriatric ward. There were three items that weren't documented in this study population: balance in the physical domain, mobility in the functional domain, and delirium in the psychological domain; these items should be emphasized for staff because they're important parameters in assessing the condition of hospitalized older adults. Of the four CGA domains, psychological health had the lowest average completeness rate, whereas socioenvironmental status had the highest average score. The overall evaluation showed that the CGA assessment wasn't optimally performed, even in the geriatric ward where it was the policy to do so. The 30-day readmission rate was 6.3%; more patients who were readmitted came from the nongeriatric ward compared with the geriatric ward, although this finding wasn't statistically significant. Similarly, the CGA completeness score of patients who weren't readmitted after 30 days was slightly higher than those who were readmitted, but again, this finding didn't reach statistical significance. In-hospital mortality was 8.1%, and older adults in the geriatric ward had significantly more deaths than those in the nongeriatric ward. However, those patients in both wards who survived had a more complete CGA. The median length of stay was 8 days (range, 2 to 62 days) and the length of stay in the geriatric ward was significantly longer than in the nongeriatric ward. Ultimately, the more complete the CGA, the longer the patient's length of stay.

Perioperative Cardiac Risk Assessment for the Frail Older Adult

Longitudinal Patient-Reported Outcomes and Clinical Outcomes By VES-13 and Comprehensive Geriatric Assessment in Older Adults with Aggressive Non-Hodgkin Lymphomas

To compare healthcare resource utilization and costs among patients with psoriasis, psoriatic arthritis (PsA), and a control group of patients without psoriasis and PsA in the USA. The IBM® MarketScan® Commercial Database was used to identify three adult patient groups from 1/1/2009 through 4/30/2020: (1) Psoriasis: ≥ 2 diagnoses ≥ 30 days apart for psoriasis (no PsA diagnoses); (2) PsA: ≥ 2 diagnoses for PsA; (3) Control: no psoriasis or PsA diagnoses in their entire claims records. Patients with comorbid rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, or ulcerative colitis were excluded from the analyses. Controls were matched 1:1 to psoriasis and PsA patients based on age, gender, index year, and number of non-rheumatological comorbidities. Healthcare resource utilization and costs (in 2019 USD) were evaluated descriptively and through mixed models for five years of follow-up. A total of 142,531 psoriasis and 21,428 PsA patients were matched to the control group (N = 163,959). Annual all-cause healthcare costs per patient were $7,470, $11,062, and $29,742 for the control, psoriasis, and PsA groups, respectively. All-cause healthcare costs increased over time and were significantly greater among PsA vs. psoriasis (p < 0.0001) and the control groups (p < 0.0001). Across all categories of healthcare resources, utilization was greatest among patients with PsA and lowest in the control group. Annual healthcare costs and resource utilization were significantly higher with PsA compared with psoriasis and the control group, confirming the substantial economic burden of PsA. The cost disparity between these patient groups highlights a continued unmet medical need. Key Points • Patients with PsA incurred significantly greater healthcare resource utilization and costs than patients with psoriasis and patients without psoriasis and PsA. • Significantly greater costs and healthcare resource utilization were also observed among patients with psoriasis compared with patients without psoriasis and PsA.

Comparison between Vulnerable Elders Survey-13 and Comprehensive Geriatric Assessment in Predicting Clinical Outcomes in Aggressive Lymphomas

BackgroundData on comparative healthcare resource utilization and costs associated with the newer oral disease-modifying therapies (DMTs) for managing relapsing-remitting multiple sclerosis (MS) in routine clinical practice are limited. The purpose of this study was to estimate healthcare resource utilization, costs, and relapse rates in the year after initiating treatment with dimethyl fumarate (DMF), interferon (IFN)-β, glatiramer acetate (GA), teriflunomide, or fingolimod in routine clinical practice for patients with MS who did not receive a DMT in the previous year.MethodsPatients initiating DMF, IFNβ, GA, teriflunomide, or fingolimod were identified based on claims data from 2012 to 2015 in the Truven MarketScan Commercial Claims Databases (n = 4194). Healthcare resource utilization assessment included the proportion of patients who were hospitalized, or had emergency room (ER) or urgent care (UC) visits. Healthcare costs were estimated for 1 year before and 1 year after DMT initiation. Relapse episodes were identified based on a published claims-based algorithm and clinical input from the research investigators.ResultsAfter DMT initiation, significant reductions in the proportions of patients who were hospitalized or requiring ER/UC visits were observed in all patient cohorts (p < 0.001 and p < 0.05, respectively). Non-prescription medical costs decreased after DMT initiation, with the largest decrease observed in the DMF cohort (US$5761 reduction, p < 0.0001). Reductions in non-prescription medical costs were associated with decreased use of outpatient services and inpatient hospital stays, and have the potential to partially offset DMT costs.ConclusionsDMT initiation is associated with reductions in healthcare resource utilization and non-prescription medical costs in routine clinical practice.Electronic supplementary materialThe online version of this article (doi:10.1007/s41669-017-0035-2) contains supplementary material, which is available to authorized users.

e16404 Background: Frailty is a critical determinant of health outcomes in older adults and may influence the management and prognosis of pancreatic cancer. The Electronic Frailty Index (EFI), a multidimensional tool derived from electronic health records, provides a standardized method to quantify frailty. However, its role in predicting healthcare resource utilization (HCRU) in older adults with pancreatic cancer remains underexplored. This study examines the association between pretreatment EFI scores and HCRU, including unplanned hospitalizations and emergency department (ED) visits, in this population. Methods: This retrospective cohort study included adults aged ≥70 years diagnosed with pancreatic cancer between 2008 and 2022 at Moffitt Cancer Center. EFI scores were calculated using pre-diagnosis data, including comorbidities, functional status, and laboratory values. HCRU was defined as the total number of unplanned hospitalizations and ED visits. Multivariable regression models adjusted for age, sex, tumor stage, treatment modality, and baseline comorbidities were used to assess the relationship between EFI and HCRU outcomes. Subgroup analyses were performed by EFI categories: low, moderate, and high frailty. Results: Among 686 patients (median age: 75.5 years, range: 70–93; 45% female), 32.8% had advanced-stage pancreatic cancer, 80% underwent chemotherapy, and 89.4% had ≥3 comorbidities (CMs). EFI classification included 27.1% as low frailty, 58.5% as moderate frailty, and 14.3% as high frailty. A trend was observed between higher EFI scores and increased HCRU; however, these associations were not statistically significant. For unplanned hospitalizations, the odds ratio (OR) was 1.15 (95% CI: 0.85–1.55; P = 0.2834), and for ED visits, the OR was 1.12 (95% CI: 0.78–1.46; P = 0.2834). Subgroup analyses revealed a similar trend but lacked statistical significance. Conclusions: This study identified a potential trend between frailty and HCRU in older adults with pancreatic cancer, though findings were limited by sample size and statistical insignificance. Further research with larger cohorts is needed to confirm these trends and explore interventions to optimize healthcare utilization in this population.

Breast cancer is the most common cancer in women in Europe and Northern America. Its incidence and mortality rates are increasing with advance in age. Only few elderly women with breast cancer are treated in clinical trials. Elderly women with the same numerical age are very heterogeneous considering their biological age. Geriatric medicine has established comprehensive geriatric assessment (CGA) to get important information on elderly patients missed by a routine clinical history and physical examination. The data collected in CGA are of prognostic relevance for mortality, morbidity, maintenance of independence and utilisation of health care resources. Within the last few years, some research groups have demonstrated that the use of CGA in elderly cancer patients collects information missed by the currently established workup of these patients and that this information is of prognostic relevance concerning toxicity of chemotherapy and mortality. The use of CGA in a population of general elderly patients improves functional status and mental health, but so far no effect on mortality could be demonstrated. A subgroup analysis of the elderly cancer patients within this trial additionally demonstrated an improvement in pain control. Special data concerning the use of CGA within the group of elderly breast cancer patients are not published so far. The authors suggest areas of care for elderly women with breast cancer within which the CGA might be able to improve treatment and which should be a field of randomised controlled trials in the future.

BackgroundPatients with ankylosing spondylitis (AS) are substantial users of healthcare resources due to chronic and potentially disabling disease. This study assessed the impact of adalimumab on clinical outcomes, healthcare resource utilization, and sick leave in patients with AS in five Central and Eastern Europe (CEE) countries.MethodsThis was an observational study in the routine clinical setting. Patients diagnosed with AS and starting treatment with originator adalimumab were followed for 12 months by assessing disease activity (Bath Ankylosing Spondylitis Disease Activity Index [BASDAI] and Ankylosing Spondylitis Disease Activity Score [ASDAS]) and physical function (Bath Ankylosing Spondylitis Functional Index [BASFI]). Data on healthcare resource utilization and sick leave were collected prospectively and compared with historical data before adalimumab initiation, as well as between treatment responders and non-responders defined by BASDAI-50.ResultsThe total effectiveness population comprised 450 patients with on average long-standing AS, high disease activity, and functional impairment. At 12 months of adalimumab therapy, mean ASDAS and BASFI scores were in the range of low disease activity and normal physical function, respectively. The mean number of hospital admissions, hospital inpatient days, and healthcare provider visits were decreased by 67.9, 83.0, and 46.3%, respectively. The number and length of sick leaves were decreased by 65.6 and 81.4%, respectively. Reductions were higher in treatment responders than non-responders.ConclusionOriginator adalimumab in routine clinical practice in five CEE countries produced clinically meaningful improvements in disease activity and physical function, and it was associated with reductions in healthcare resource utilization and sick leave.

Chronic obstructive pulmonary disease (COPD) is a prevalent condition mainly related to smoking, which is associated with a substantial economic burden. The purpose was to compare healthcare resource utilization and costs according to smoking status in patients with COPD in routine clinical practice. A retrospective cohort nested case-control study was designed. The cohort was composed of male and female COPD outpatients, 40 years or older, covered by the Badalona Serveis Assistencials (a health provider) health plan. Cases were current smokers with COPD and controls (two per case) were former smokers with COPD (at least 12 months without smoking), matched for age, sex, duration of COPD, and burden of comorbidity. The index date was the last visit recorded in the database, and the analysis was performed retrospectively on healthcare resource utilization data for the 12 months before the index date. A total of 930 COPD records were analyzed: 310 current and 620 former smokers [mean age 69.4 years (84.6 % male)]. Cases had more exacerbations, physician visits of any type, and drug therapies related to COPD were more common. As a consequence, current smokers had higher average annual healthcare costs: €3,784 (1,888) versus €2,302 (2,451), p < 0.001. This difference persisted after adjusting for severity of COPD. Current smokers with COPD had significantly higher use of healthcare resources, mainly COPD drugs and physician visits, compared with former smokers who had abstained for at least 12 months. As a consequence, current smokers had higher healthcare costs to the National Health System in Spain than ex-smokers.

Background There is an abundance of evidence to demonstrate the positive impacts of Comprehensive Geriatric Assessment (CGA) on clinical and process outcomes for older adults across settings of care. However, it is unclear how older adults themselves view CGA and their experiences of the care process. The aim of this qualitative evidence synthesis is to explore the experiences and perspectives of older adults of CGA. Methods A comprehensive literature search was completed across MEDLINE, CINAHL, PsycINFO, PsycARTICLES and Social Sciences Full Text. Qualitative or mixed methods studies that included qualitative data on the perspectives and experiences of older adults of CGA were included. The methodological quality of the included studies was appraised using the Critical Appraisal Skills Programme checklist for qualitative research. Findings were synthesised using thematic analysis Results Nine studies were included in the synthesis, including studies where CGA was completed in hospital, outpatient assessment unit and home settings. Divergent experiences of CGA were reported. Older adults reported experiences of being respected and listened to during CGA and attention paid to all their issues and priorities. Good communication by healthcare providers was central to these positive experiences (theme 1). In contrast, experiences of being unclear about the aim of CGA or perceived benefits of CGA, feeling that the outcome of CGA did not align with their priorities (theme 2) and not feeling involved in decision making during CGA (theme 3) were also commonly reported. Conclusion Findings indicate that CGA is a process by which older adults can felt respected and paid attention to. However, scope exists to further improve older adults’ experiences of CGA. Enhanced healthcare provider communication and facilitation of older adult involvement in decision-making are priority areas for improvement. Further research should focus on exploring other stakeholder groups experiences of CGA including caregivers and healthcare professionals.

M. LYCKE, MSC, Cancer Centre, General Hospital Groeninge, Kortrijk, L. POTTEL, MSC, PHD, Cancer Centre, General Hospital Groeninge, Kortrijk, T. BOTERBERG, MD, PHD, Department of Radiation Oncology, Ghent University Hospital, Ghent, L. KETELAARS, MSC, Department of Psycho-oncology, General Hospital Groeninge, Kortrijk, H. WILDIERS, MD, PHD, Department of General Medical Oncology & Leuven Cancer Institute, Leuven University Hospital, Leuven, Belgium, P. SCHOFIELD, DIPN, PGDIPED, RGN, PHD, Centre for Positive Ageing, University of Greenwich, London, D. WELLER, MBBS(ADEL), MPH, PHD, FRACGP, FRCGP, FAFPHM, FRCP(EDIN), Centre for Population Health Sciences, University of Edinburgh, Edinburgh, & P.R. DEBRUYNE, MD, PHD, MSC, FRCP(GLASG), FCP, Cancer Centre, General Hospital Groeninge, Kortrijk Belgium, & Centre for Positive Ageing, University of Greenwich, London, UK

Comprehensive Geriatric Assessment in the Older Adult with Cancer: A Review

Income-based deductibles are present in several provincial public drug plans in Canada and have been the subject of extensive debate. We studied the impact of such deductibles in British Columbia's Fair PharmaCare plan on drug and health care utilization among older adults. We used a quasi-experimental regression discontinuity design to compare the impact of deductibles in BC's PharmaCare plan between older community-dwelling adults registered for the plan who were born in 1928 through 1939 (no deductible) and those born in 1940 through 1951 (deductible equivalent to 2% of household income). We used 1.2 million person-years of data between 2003 and 2015 to study public drug plan expenditures, overall drug use, and physician and hospital resource utilization in these 2 groups. The income-based deductible led to a 28.6% decrease in person-years in which public drug plan benefits were received (95% confidence interval [CI] -29.7% to -27.5%) and to a reduction in the per capita extent of annual benefits by $205.59 (95% CI -$247.81 to -$163.37). Despite this difference in public subsidy, we found no difference in the number of drugs received or in total drug spending once privately paid amounts were accounted for (p = 0.4 and 0.8, respectively). Further, we found only small or nonexistent changes in health care resource utilization at the 1939 threshold. A modest income-based deductible had a considerable impact on the extent of public subsidy for prescription drugs. However, it had only a trivial impact on overall access to medicines and use of other health services. Unlike copayments, modest income-based deductibles may safely reduce public spending on drugs for some population groups.

Introduction It is well established that older adults with hip fracture benefit from comprehensive geriatric assessment (CGA), but there is less evidence for its use in major trauma. Since 2012 Major Trauma Centres (MTCs) have opened across the UK, with varying access to CGA. We report the requirement and impact of CGA in a MTC in its first year of opening. Methods We reviewed all adult patients admitted under the South-East Scotland MTC included in the Scottish Trauma Audit Group (STAG) database from 1st November 2021 – 31st October 2022. We compared: patients under 65y, patients ≥65y who did not undergo CGA, and patients ≥65y who underwent CGA. Outcomes were: review by ED consultant within one hour of presentation, trauma team activation, injury severity score (ISS), CGA within 7 days when CFS≥5, and mortality at 30 days. Results 1323 patients were identified (mean age 63.7y, SD20.9): &amp;lt;65y (n=690, 45.5y, SD14.0), ≥65y without CGA (n=401, 77.2y, SD8.2), and ≥65y with CGA (n=289, 84.6y, SD 7.3). The commonest mechanism of injury in all three groups was fall from standing height (29.1%, 59.6%, and 73.4% respectively). ED consultant review within 1 hour occurred in 37%, 25% and 18% of cases, with trauma team activation occurring in 32%, 18% and 7%. Average ISS were: 13, 12 and 11, and commonest sites of injury in those over 65 were external (e.g. skin), chest and limb. CGA was undertaken within 7 days in 95.1% of those with a documented CFS≥5. Mortality at 30 days was 2.9%, 12% and 8%. Conclusions A fifth of patients admitted to our MTC in the first year were older adults with CFS≥5. These patients were under-triaged at several stages despite comparable average ISS across groups. CGA may reduce 30-day mortality. We recommend further research into the benefit of CGA within MTCs.