Can Comprehensive Geriatric Assessment be delivered without the need for geriatricians? A formative evaluation in two perioperative surgical settings

Why it matters

Most older people will need acute care services at least once every four years. And when they do go into hospital, they are at a high risk of poor outcomes.

Older people who show signs of frailty are especially vulnerable. They are six times more likely to have a prolonged hospital stay, 50% more likely to be quickly readmitted, and 70% more likely to die than those who are not frail.

Some of these risks can be mitigated by using a Comprehensive Geriatric Assessment (CGA), a process to identify the complex needs of frail older people and develop and deliver a plan to meet those needs. CGA has been shown to reduce mortality and institutionalisation, but it is only implemented in certain areas of many acute hospitals.

This study aimed to find out whether the principles of CGA can be embedded in hospital units where it is not part of routine practice, and whether it can be done without the need for geriatricians.

Our approach

The study involved developing, piloting, and evaluating a complex intervention to help non-geriatric teams improve the care they offer to frail older people.

This intervention took the form of a toolkit based on the principles of CGA, which was developed using qualitative methods, a literature review, and co-production with stakeholders, including patients and members of the public.

The toolkit was then piloted with healthcare staff in peri-operative/surgical cancer care in two large teaching hospitals in the UK. Over 12 months, a qualitative evaluation was conducted.

What we found

• Though clinicians were initially enthusiastic about the toolkit, the extent to which it changed practice was limited.
• The toolkit’s impact was likely impeded by competing priorities, like national time-limit targets (particularly around timeframes for treatment in areas like cancer, which limited the opportunity to do CGA) and concerns about patients’ immediate treatment and recovery.
• Sites concluded that pre-operative assessment was not the best place for CGA.
• Teams felt that this was not something they could undertake themselves without expert support, and they needed ongoing input from a geriatrician. But there aren’t enough geriatricians in the UK to manage all frail older inpatients – and that gap will increase as the population ages.