A geriatric assessment intervention in primary care provided by a nurse or a GP (CEPIA) : a cluster-randomised trial

Veronique Orcel, Julie Fabre, Sylvie Bastuji-Garin, Vincent Renard, Emmanuelle Boutin, Philippe Caillet, Elena Paillaud, Leon Banh, Claude Attali, Etienne Audureau, Emilie Ferrat

Background:

Comprehensive geriatric assessment (CGA) is a multidimensional holistic assessment of the health status of elderly people. Although its benefit is known in hospital care, its impact is uncertain in primary care.

Research questions:

We hypothesised that a complex intervention including a CGA adapted to primary care, educational training and specialised geriatric hotline to support GPs would be more effective on morbimortality of over-70s with chronic conditions than usual care in primary care.
The primary objective was to assess the 1-year morbimortality with a composite criterion combining all-cause mortality, emergency visits, hospitalisations, and institutionalisations.
Secondary objectives were assessed on each component of the composite criterion, quality of life, autonomy, polypharmacy, and care actions delivered.

Method:

The CEPIA study is a cluster randomised trial in 3 parallel arms between May 2016 and November 2017 in France.
Inclusion criteria were: patients over 70, with a long-term illness scheme or an hospitalisation in the past 3 months.
In arm 1, a systematic CGA (adapted to primary care) was provided by a nurse and in arm 2 a case-by-case basis CGA (adapted to primary care) was implemented by GPs. Arm 3 was usual care (control group).
Patients were followed up for 12 months, with 3 assessments (baseline, 6-month, 12-month).
Cluster randomisation was at the GP practice-level.

Results:

39 practices (89 GPs) included 634 patients: 231 in arm 1, 190 in arm 2 and 213 in arm 3.
In ITT analysis, after adjusting and multiple imputations, arm 2 tended to be significant, with p = 0.055 (adjusted OR [IC95%] = 0.64 [0.41-1.01]). Arm 1 was not statistically significant.

Conclusions:

This study shows the effectiveness of an adapted CGA in primary care when provided by GPs. Delegation of tasks to nurses, with no real collaborative work, could explain the failure of the arm 1.

Points for discussion:

No GP called the geriatric hotline among the 2 interventional arms

More blood tests and medical imaging were prescribed in the control group

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