Adhering to inpatient geriatric consultation recommendations

Journal of Family Practice, March, 1996 by Charles A. Cefalu

Background. The purpose of this study was to evaluate the rate of and factors associated with attending physicians' adherence to geriatric consultation recommendations in an urban community hospital.

Methods. A retrospective review was performed of the charts of 47 patients referred for inpatient geriatric consultation over the previous 1 1/2-year period. Study variables included patient and attending physician demographics, length of stay in hospital before geriatric consultation, status of patient on discharge, level of expertise of consultant, number of diagnoses per patient, and types and number of recommendations per patient made by consultant and acted upon by attending physicians.

Results. The recommendations made included medical (23.4%), medication (28.6%), laboratory (15.8%), radiological (2.6%), nutritional (11.7%), psychosocial (7.7%), skin care (1.6%), rehabilitative (6.4%), and other (2.2%). The percentage of total recommendations acted upon was 55.5%. By multivariate analysis, decreasing length of time prior to consultation was statistically associated with referring physician adherence to consultation recommendations (P=.03). Slightly more than 40% of the variability in adherence was explained by this single variable.

Conclusions. Inpatient geriatric consultations are aimed at providing a comprehensive assessment for attending physicians. Recommendations are acted upon more than 50% of the time. Physician adherence to recommendations does not appear to be dependent on patient or physician demographic variables, but to some extent, adherence is associated with less time in the hospital prior to consultation. This is a relatively new concept in hospital medicine.

Key words. Community hospital; geriatrics; assessment; consultants. (J Fam Pract 1996; 42:2.59-263) Although geriatrics remains a relatively new discipline, several descriptive and experimental studies have shown that geriatric evaluation and management programs have the potential to significantly improve patient outcomes. 1-3 Inpatient geriatric consultation has been shown to play a critical role in the acute care of the elderly, but it is often limited by reimbursement issues4 and scarce resources.[5]

Geriatric assessment is usually accomplished by inpatient geriatric teams consisting of a geriatrician, a registered nurse, and a social worker, and often a physical therapist, an occupational therapist, and a nutritionist.[6] This interdisciplinary team has the capacity for multidimensional diagnosis and planning with respect to medical, psychosocial, and rehabilitative care. Geriatric consultation can be provided in one of four ways: by instituting a hospital-wide policy to evaluate all patients over the age of 75; by consultation on request; by routine follow-up of all patients cared for by other geriatric services, such as home care or a geriatric clinic[7]; and by targeting geriatric consultation to the attending physicians caring for special groups of the elderly patients who are neither too sick nor too well to benefit.[8-10] Most geriatric services are integrated with internal medicine or surgery departments.[7]

Factors reported to affect adherence to general medicine consultations include identifying critical and definite recommendations, making early, direct oral recommendations, and limiting their number.[11] In one study evaluating factors affecting adherence with respect to the recommendations made in 202 of these consultations, adherence decreased as the number of recommendations increased. Adherence was shown to increase with more severely ill patients when the number of recommendations was limited to five or fewer. The overall adherence rate was 77%.[12] In a prospective randomized controlled study by Allen et al[13] evaluating the effectiveness of a geriatric consultation team, adherence to recommendations was 71.7%. In a study performed at a veterans medical center[5] that explored the extent to which a physician-administered multifaceted assessment could meet the needs of a geriatric consultation service, adherence with recommendations was poor, averaging less than 33%. Finally, several studies suggest that the nature of the relationship between the attending physician and consultant may be a more important determinant of adherence than is the soundness of the recommendations.[14]

The concept of geriatric consultation performed solely by a university-based primary care physician in a community hospital setting is a relatively new concept in health care delivery. Such an approach offers a unique combination of the added expertise in geriatric medicine while encompassing the holistic approach of primary care. As the United States population ages and as health care reform shifts priorities to primary care and teaching from the university to community hospital setting, this concept will receive a growing share of attention. This study seeks to evaluate the rate of and factors associated with attending physicians' adherence to geriatric consultation recommendations made by an academic primary care geriatrician in a community hospital.