Comprehensive geriatric assessment for older adults admitted to ...

AARP Ageline (from 1978 to April 2010). In addition, we checked
reference lists of all papers and reviews as well as conference proceedings
of the American Geriatrics Society and the British Geriatrics
Society.
The search strategy for MEDLINE is shown in Appendix 1 and for
EMBASE in Appendix 2. We adapted this for the other databases.
Data collection and analysis
Selection of studies
Three independent review authors (GE, DR and MW) screened
titles and abstracts of papers identified by the literature searches for
their potential relevance. We excluded any papers that did not meet
the inclusion criteria at this stage. Where there was a disagreement,
we considered the paper as potentially relevant and proceeded to
the next stage. We retrieved all papers of potential relevance and
three independent review authors (GE, DR and MW) assessed the
full text for inclusion in the review. Where there was disagreement,
GE and DO’N moderated; reasons for excluding full papers are
reported.
Data extraction
We performed data abstraction using a pre-designed data abstraction
form on all studies that fulfilled the inclusion criteria. Two
review authors (DR and MW) abstracted the data independently,
including data on design characteristics, the study population, the
intervention, outcome measures used and length of follow up. We
determined classification of the intervention by characteristics of
the form of CGA used (discrete geographical unit versus mobile
team) and the components of the interventions. Disagreements
were resolved by the moderators (GE and DO’N).
Assessment of quality
We assessed all relevant trials to evaluate and record potential
sources of bias using recognised methods (Cochrane 2011; Hayden
2006). This included assessment of quality of randomisation procedure,
concealment of treatment allocation and blinding of participants.
Analysis
We considered study characteristics such as population, time to
enrolment and length of follow up in the analysis and grouped
studies based on these characteristics.
For the purpose of the outcome institutionalisation, we combined
the presence of the patient in a care home, a hospital ward or longterm
institutional care to avoid differences in outcomes related
to the healthcare system of the country in which the trial was
conducted. Only those discharged to their own home (rather than
residential care, etc.) were classified as at home.
The original intention in the protocol was to use a primary outcome
of independent survival. This combined outcome is the inverse
of death, institutionalisation or disability together and might
be defined as the odds of someone surviving in the community
without being dependent. It was not possible to measure this as
many studies that reported disability did not report this separate
to institutionalisation. For this reason it was not possible to exclude
double-counting. Thus we performed the analysis using the
primary outcome ’living at home’ (the inverse of death or institutionalisation)
or the odds of a patient being alive and in their own
home at a defined time point.
Outcome measures were dichotomous, ordinal and continuous.
Many of the outcome scales were ordinal and where necessary,
we converted these to dichotomous data (e.g. in the calculation
of dependency). Results are presented separately for ’wards’ and
’teams’ for each domain of outcome and where it was possible to
dichotomise data, we calculated odds ratios and 95% confidence
intervals for each study and presented the results for each subgroup.
Where significant heterogeneity existed we applied a heterogeneity
(I 2 statistic) threshold of 70% as the level at which data
would not be pooled for analysis. No meta-analysis was performed
where grossly differing outcome measures precluded combination.
Where it was not possible to dichotomise the data, or continuous
scales were used, we attempted meta-analysis using weighted mean
differences. Results are presented with numbers needed to treat
where results are statistically significant, however it must be noted
that these must be interpreted as representing a pooled result and
will be dependent on the control event rate.
Subgroup interaction is reported only where the results of overall
analysis are significant and the differences between subgroups are
also statistically significant.
R E S U L T S
Comprehensive geriatric assessment for older adults admitted to hospital (Review)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies.
(See also Characteristics of included studies; Characteristics of
excluded studies).
We retrieved a total of 28,843 titles (search date April 2010, Figure
2). We reviewed 170 abstracts and selected 48 papers for fulltext
screening. We excluded 26 studies. Eleven studies did not use
randomised controlled trial methodology (Boult 1994; Campion
1983; Gayton 1987; Hogan 1990; Ledesert 1994; Liem 1986;
Meissner 1989; Miller 1996; Mudge 2006; Reuben 1992). We
identified no cluster-randomised controlled trials. Six studies evaluated
CGA in an outpatient or elective setting (Cunliffe 2004;
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