Comprehensive Geriatric Assessment: Benefits, Cost-Effectiveness, and Who It Helps Most: Eric Wong and Thiago Silva

Eric Widera 00:06

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:13

This is Alex Smith.

Eric Widera 00:14

And Alex, who do we have with us today?

Alex 00:17

Today we are delighted to welcome from the great state of Canada,

Alex 00:25

… I mean from the great country of Canada. [laughter]

Eric Widera 00:28

Oh, we’re gonna get a lot of comments on that one, Alex. [laughter]

Alex 00:33

We’re delighted to welcome Eric Wong, who is a geriatrician and researcher, PhD candidate at the University of Toronto, who practices geriatrics at St. Michael’s Hospital. Eric, welcome to the GeriPal podcast.

Eric Wong 00:46

Thank you. Thank you for inviting me.

Alex 00:47

And we’re delighted to welcome Thiago Silva, who’s a geriatrician from Brazil and is currently a T32 postdoctoral research fellow at UCSF in the Division of geriatrics. Thiago. Welcome to GeriPal.

Thiago 01:00

Thanks. Great to be here.

Eric Widera 01:02

So we’re going to be talking about comprehensive geriatric assessments. A topic that I have a vague, foggy idea exactly what it is, but we’re going to be talking about what it is, who should get it and what’s the evidence base. But before we go into all of that, Thiago, I think you have a song request for Alex.

Thiago 01:22

Yeah. Our song request today is Getting Older by Billie Eilish. And I like that song because it kind of shares a reflection on getting older, cumulative life experience. And that’s why I requested that song.

Eric Widera 01:41

Isn’t Billie Eilish like 18?

Thiago 01:47

Well, maybe in her soul she’s older.

Eric Wong 01:50

Little bit older.

Alex 01:59

It’s a great song. She’s such a good singer. Here’s a little bit of Getting Older.

Alex 02:17

(singing)

Eric Widera 04:23

Wonderful. Thank you, Alex.

Thiago 04:25

Pretty good.

Eric Widera 04:26

Good song, Thiago. All right, Eric, I gotta ask. What the heck is a comprehensive geriatric assessment?

Eric Wong 04:35

So the comprehensive geriatric assessment, in my view, is just sort of like the most common tool that a geriatrician uses to assess an older adult with complexity or with frailty. And there are a lot of definitions, and I think there was an umbrella review a few years ago discussing what the definition is because there’s so many out there. But I think the commonalities include it being multi dimensional. So it has to assess multiple domains, it has to identify geriatric issues, and it has to come up with a plan to manage those issues. That’s my impression.

Eric Widera 05:11

And Eric, you do CGAs in your practice, right? Comprehensive geriatric assessments?

Eric Wong 05:16

Yeah. Yeah.

Eric Widera 05:17

What does that look like for you?

Eric Wong 05:19

So basically, in our practice in Toronto, generally we mainly do CGA. So we mainly do consultations on new patients, whether they’re in the acute care setting, in the rehab setting, or in the clinic. And some of us, for the outpatient clinics, we will follow people longitudinally. So the comprehensive geriatric assessment would be the first visit where we do a longer assessment, and then the follow ups would be sort of more focused on. On the individual domains or issues that the patient has. But in general, we. We do the CG. Like, that’s basically our main practice is doing CGAs.

Thiago 05:55

Yeah.

Alex 05:56

What domains do you cover?

Eric Wong 05:59

We. So we do a lot of different domains, but I think the most common ones are cognition, falls, you know, mood, multimorbidity, polypharmacy, those kind of geriatric syndromes, and tiago.

Eric Widera 06:14

Did you do them in Brazil?

Thiago 06:16

Yeah, we do them in Brazil as well. And I guess one thing that I like about CGA is that I think it addresses one of the core principles of geriatrics, which is like establishing priorities. You know, you have these older adults, failure adults, very complex, a lot of things going on at the same time. And through a cga, you kind of have a. An objective measure of the problems that are going on, and then you can plan with your patient and their families, which should be addressed first and how to do that.

Eric Widera 06:48

So I got a question. So I remember going back to geriatrics fellowship. Like, I have my geriatrics clinic. I saw the patient individually, I talked with the attending, it came back. If I needed a social worker, I would get a social worker involved. Or if I needed the pharmacist, I would get the pharmacist involved. And I hear about these other. What I always thought was comprehensive geriatric assessments where, like, it was a big team, each individual, like they were being.

They were seen by the rn, a geriatric specialist, a geriatric pharmacist, a social worker. They were all coming up with their assessments, then they met together and then they came up with a plan. Like, it was this, like, half day, sometimes full day. Maybe it was more of the geriatric evaluation and management type clinic. Is that a comprehensive geriatric assessment or was Eric Widera just coming in there as the lone geriatrician doing his best to do an assessment?

Alex 07:42

Yeah, the half day, full day sounds like big C, putting the C in.

Eric Widera 07:46

Comprehensive, comprehensive versus the Eric. Maybe it was just the geriatric assessment without the C. No comprehensiveness in there.

Eric Wong 07:55

Yeah, no, I think the. So the definition that these authors came up with in 2018 included multidisciplinary as one of the requirements. I have to say that in Canada, and I can’t speak on behalf of all of the different practices because they’re quite diverse. There are some places where they do, in fact have that, like an outpatient geriatric assessment would have different visits. Whereas, you know, by one visit they do a pharmacist, do a med rec, and then they may get, you know, a nurse to do one of the histories sessions and then like PT and OT may see them separately and then the geriatrician brings it all together and then does the assessment and plan.

So there is that model, but I think the. The majority of geriatricians just kind of do most of the CJ themselves, or maybe with one or two allied health, but. But not with like a big team.

Eric Widera 08:47

Yeah. And in your experience, Thiago.

Thiago 08:50

Yeah, I think the multidimensional aspect of it is like the. Probably the central piece. And then there are different ways that you could do that, you know, by yourself or whether with a team. There are settings where there are geriatricians, as we’re going to discuss, and. And then you might have other professionals doing these assessments and you can even have like, short, targeted kind of CGAs, which is another approach as well.

Alex 09:17

So it sounds like comprehensive geriatrician assessment. It’s the comprehensive geriatrics assessment, which can be done by non geriatricians.

Thiago 09:26

Yeah, that’s right.

Eric Widera 09:28

But it also sounds like, there is a spectrum. Right. You can’t have a highly trained in multidisciplinary people with expertise in geriatrics, from geriatric pharmacists, geriatricians, like the whole works, seeing patients in different types of settings to the other end of the spectrum where it’s maybe less resource intensive than that, but potentially still doing the components of a comprehensive geriatric assessment. Maybe not as intensive as that other end of the spectrum.

Thiago 10:00

It might not be intensive, but like, you’re intentional, right? You’re having this look into things that many times people don’t really value in clinical care. And that’s where I think the CGA can help, that you’re intentionally evaluating these issues and then you can plan for interventions and. And care.

Eric Widera 10:22

Yeah. And the intentional part, like, are those the. So you. They may do screening tests beforehand, you know, report outs, cognitive screeners. You’re intentionally evaluating for geriatric support.

Thiago 10:36

Yeah. Okay.

Alex 10:38

And I’m still trying to figure out what’s in there. So are geriatric syndromes always assessed? Like, is that an essential component of a comprehensive geriatric assessment, like incontinence, for example? You mentioned falls, but are all.

Thiago 10:54

I think it varies a little bit.

Eric Wong 10:55

Right.

Thiago 10:56

But I think like Eric said, you always have cognition, you always have like, function. You’re going to have some, usually some, some measure of social support, nutrition, polypharmacy. There might be sometimes, you know, falls, history of falls, sometimes measure, you know, some kind of resource utilization, kind of, you know, whether they were admitted to the hostel or visited the ed, you know, recently. Sometimes it’s a part of it as well. And mobility, mood.

Alex 11:33

Eric, anything you’d add?

Eric Wong 11:35

Yeah, no, I agree. So they’re, you know, the five M’s. Like, I think, you know, as mentioned, like, those are great domains and yeah, I agree. Like in our CGAs, we also do a review of systems where we kind of go through those things that you might. That might not come out unless you directly elicit them, like urinary incontinence or constipation, appetite, sleep, weight loss, that kind of stuff. So, yeah, we include all those things. And then sometimes in the right context, we would do objective testing, so cognitive testing or objective mood testing in a scale. And also the physical, of course.

Alex 12:14

And I’m glad you mentioned the 5M because that was going to be my next question. Like, how does this relate to the 5M conceptually? Because we’re seeing this great uptake of the. What is it called? The age friendly health system framework. Right. Which Includes I think they have four M’s, but you know, you’re probably adding the five M’s. Five fifth M is what multi complexity.

Eric Widera 12:37

Mind mobility, medications what matters. And multi complexity. I looked that up because I want to make sure I got that right. I also never know am I supposed to use 4M’s or 5M’s?

Alex 12:54

Is that framework kind of replacing the comprehensive geriatric assessment? I’m just trying to figure out how they’re related. What’s the relationship between these two concepts?

Thiago 13:03

Yeah, I don’t think they’re replacing. Right. I think it’s like CGA is probably a tool, a resource to implement the 5Ms.

Eric Widera 13:12

Or is it specific population, A comprehensive geriatric assessment. The word comprehensive means that you’re doing a lot. Does everybody need a comprehensive assessment versus does every older adult need. We should focus on the 5Ms. For me, that almost feels a little bit different. What do you think, Eric?

Eric Wong 13:32

Yeah, I think it depends on the purpose in the context of where the practice is and the goals of the practice. But I think 5 Ms. Is sort of an easy way to disseminate geriatrics knowledge to say, non specialists to general practitioners and they can understand that, oh, these are actually core geriatric concepts that if you were to do, say internal medicine and you don’t think about this and you would completely miss very important geriatric syndromes.

And it’s easy to remember it’s a good mnemonic. And I like that. It also says matters most, which is we always factor in patient preferences into our consult. So I think it’s more of geriatricizing like big G, little G kind of, you know, of the entire healthcare system. But I think for a cga, we do a little bit more than that. And I think part of the problem is, you know, if you’re not systematic. Right. Sometimes you would miss issues. And so the CGA takes a long time because it’s a systematic approach so that, you know, we pick up on the issues that maybe others have missed. And I think a lot of the value that’s come from that.

Eric Widera 14:40

And I’m guessing, Eric, you’ve been doing this for some time. Do you just kind of remember everything? Do you have like a structured CGA assessment that you go through every single time?

Eric Wong 14:51

Oh yeah, like it definitely. And I’m admitting this online to all of my preceptors who may watch this. But it did take me a long time to actually memorize all the elements. Like even though, you know, in training, like in our geriatric residency, we do it all the time, but we use a template generally because it’s such a long consult. But I have to say, even after independent practice, it took me a bit of time to actually get it down. But now, of course, after doing it for a number of years, it’s more or less memorized. I could do it the best with a blank piece of paper.

Eric Widera 15:28

How long does your comprehensive geriatric assessment take?

Eric Wong 15:33

So as a standard in where I practice in Ontario, I think the standard is 90 minutes for a comprehensive geriatric assessment, but it does vary in some contexts. Some geriatricians may be a little bit more focused depending on the reason for the referral. And in a lot of cases, we end up taking a lot longer because there’s a lot of complexity, there’s a social aspect, there’s multiple family members, informants who we need to get different perspectives of. So it would not be surprising for us to take up to three hours. But in terms of the standard, as what the.

Because in Canada it’s a single payer health system, so all the billings go through the government. So the government’s requirement is 90 minutes for that CGA.

Thiago 16:24

Yeah, I agree that usually, like for us in Brazil, we usually take about an hour, but it will vary anywhere between 45 minutes and 2 hours depending on the patient.

Eric Widera 16:37

So does it work? What evidence do we have? And I think there’s probably some connection to the body of evidence we have for palliative care, because in that evidence is like, oh, does palliative care work? My response is, what do you mean by palliative care? What components do you have to include to be called a palliative care intervention? Is it primary palliative care specialty, palliative care? How many disciplines have to be involved?

How many domains of palliative care have to be involved till we call this like it reaches that bar? I’m getting a sense from a CGA too, like, there’s probably a lot of variability in the studies out there, but it makes sense. Tiago, does comprehensive geriatric assessment do anything from an evidence perspective?

Thiago 17:26

I think there’s pretty good evidence that it does do something and it’s usually good stuff. There are even more recent meta analysis and several studies on different settings looking into how integrating CGA into care affect outcomes. I think generally the results are pretty positive and improving length of stay, improving functional recovery, preventing longer hostile stays and readmissions. But there is some variability regarding the costs and results in these different scenarios.

So there are studies that were able in the inpatient setting to find benefits regarding functional outcomes. But then you might see some increase in costs. There are studies in the ED showing that they were able to decrease costs and decrease their stay in the ed, but then the revisit rates increase a bit. So the different approaches to how you do it and how you do it integrated into these different scenarios do affect the evidence. They’re heterogeneous. Yeah.

Eric Widera 18:57

I remember reading a meta analysis, BMJ, I think, back in 2011, did a meta analysis looking at inpatient comprehensive geriatric assessment. People were more likely to be alive and in home for those who got the comprehensive geriatric assessment. And it seemed like it was. Again, there’s the variability. What do we call that? Like, the more like, if it was its individual unit, I believe it actually maybe had a little bit more evidence than if it wasn’t. And again, this variability of like, how are we delivering this comprehensive geriatric assessment? Yeah, Eric, you want to say something?

Eric Wong 19:35

And I think. Yeah, no, I agree. And I think one of the factors is, you know, if you do the assessment, but then the recommendations don’t get implemented, then the effectiveness of that assessment would decrease. Right. And so in a geriatric unit, it makes sense because there is, you know, it’s sort of like you’re implementing everything that you recommend because you. The team works with you and you could carry that through all the way till the end.

And so that it makes sense. Right. But in some other models, maybe just a consultation is delivered and you rely on other providers to carry through those recommendations. And I think there have been some studies, especially in geriatric oncology, looking at what percentage of recommendations get implemented. And the numbers can vary quite a bit, can be low, and so then the effectiveness might not be as good.

Thiago 20:28

And I think that’s a really important message because I feel that when we talk about CGAs, we often focus on the assessments and less so on the, you know, the care plans. And that’s really why we’re doing it. Right. We’re not just there to, you know, time how long someone takes to, you know, get up and sit down, you know, and sit on the chair that’s supposed to be used for something. Yeah.

Eric Widera 20:55

So I’m hearing there is the assessment, there is the implementation. I also read a third key component for a geriatric assessment is screening and targeting the right individuals. So that’s really the first step is who benefits from this? Because I also read maybe there’s spectrums, like very, very healthy older adults may not Benefit it. Very, very sick. Older adults may not benefit from it. So is there a sweet spot? What do you think about that?

Alex 21:32

And I think that the very, very healthy is kind of intuitive. The very, very sick. I don’t quite understand and would love to have an explanation about that.

Eric Widera 21:41

If it’s true. If it’s true. What I read.

Eric Wong 21:45

Well, yeah, I mean, I agree. Right. So you have to choose the right people. And I think part of the issue is if you don’t do the assessment, you actually may not figure out all the issues that are hidden in somebody who otherwise appears healthy. So, you know, as St. Michael’s Hospital, we do automatic consults on people over the age of 65 with a hip fracture, and we also see people over the age of 65 with a trauma, and we do automatic consults on all these people. And this is pioneered by one of my colleagues, Dr. Camilla Wong, who started these services and that were.

Eric Widera 22:25

That’s a very select population. Right. Like the fact that they have a hip fracture.

Eric Wong 22:29

Yes.

Eric Widera 22:30

Means that something is going on. Like, these are not, like.

Eric Wong 22:34

Yes, they’re not general population. But the hip fracture is one thing, so there’s good evidence for that. Right. Ortho geriatric care. But the geriatric trauma is a little bit interesting. So, yes, a lot of them may have falls. Right. They may fall down the stairs and fall itself would be a geriatric syndrome. So there’s an inciting event and you’re selecting for people who present with the geriatric syndrome. But there are also traumas where it’s just a car accident, for example, not just a car accident, but it’s a car accident. And. And then you have to actually dig further to figure out, like, were they the driver, were they the passenger, what kind of injuries?

Thiago 23:07

And.

Eric Wong 23:07

But it’s. It’s actually surprising because a lot of these people, just by age alone, they actually have issues that we can address when we talk to the families. Like they may be struggling with some cognitive changes that, you know, because primary care is. There’s a crisis in Canada, it’s hard to find a family doctor. They may not have brought it up to anybody and the first time, because we saw them and it’s just that they’re older. Right. And we’re identifying these issues. So there’s a lot of cases where we could find something even in people who don’t specifically present with a geriatric syndrome.

Thiago 23:40

Yeah. I think we have to be careful as well when we say that something doesn’t work. We have to think on what kind of outcome is being used to say that it doesn’t work. Right. So Alex, when you say that, you know, I’ve heard that it, you know, CJ’s that don’t, don’t work for very old or very frail or adults. So what doesn’t it work for?

Eric Widera 24:03

So isn’t the primary thing everybody cares about patients is their length of stay and hospital utilization. That’s what matters most, right? That’s 5M. That’s the last profit margin for healthcare industrial complex.

Thiago 24:21

So there you go. Right? So then it’s probably not going to work. So there probably be, you know, throughout the lifespan and complexity, there probably be components in the CGA that will be, you know, stuff that you can intervene more or less depending on the patient. So you might not be able to improve their cognition, but you can, you know, identify social support problems and help them address those issues. So yeah, I love that point.

Eric Widera 24:54

It reminds me of Ken Kavinsky during our last updates at AGS where we were talking about hearing loss and the outcomes of like hearing aids with cognitive impairment. And ultimately like the, the main point I heard from Ken was, hey, just the fact that they can hear is an outcome that’s good enough, right? Like you don’t need to show like it prolongs life or it decreases cognitive impairment.

Speaker 5 25:24

Like they can hear.

Eric Widera 25:26

That’s important.

Thiago 25:28

Thanks, that was a really good point. Yeah.

Alex 25:30

And Tiago, we mentioned when we first were asking you about what is a comprehensive geriatric assessment, you were talking about like prioritization, which to me reminds me of the M what matters most. And I’m wondering if is that a part of the comprehensive geriatric assessment?

Thiago 25:48

It should definitely. It definitely should be. Right. And now that you explicitly ask and Eric can tell us about his experience, but I think it’s rare that a CGA model will explicitly have that there, that component, like ask your patient what matters most. It’s more like what you as the provider is identifying as what matters most. But that would be a very good point that we should include that, you know, that M more explicitly in the models.

Eric Widera 26:25

What do you think, Eric?

Eric Wong 26:27

Yeah, yeah, no, I agree. And so I think at the end of my consul notes, I often will try to have a point on future planning where I’ll in the right context talk about goals of care, advanced care planning, and also what their preferences are. And in some consult, it’s more important than others. Right. When we see people, for example, with malignancy or with other end stage diseases, it’s more important to Prioritize that and talk about those preferences. But sometimes even for my clinic patients, I will ask them, like, where do you see yourself aging?

Like, do you want to stay in place and age at home? Or do you want to move in with one of your children? Or do you want. And some people actually want to go to a retirement home. They’re like, I have friends who are in retirement home and they have a great time. And so how did it get me into one of those places? And so. But I do find that if I don’t ask that questions, people are either we’re so focused on medical issues that we forget about it, or they don’t know whether they should bring it up. But asking that specifically, I find it very helpful.

Thiago 27:32

Yeah.

Eric Widera 27:33

And again, I think where I was reading about the spectrum, the very, very healthy or low, the very, very sick is, is not like the little C comprehensive geriatric assessment. It was like the big C. Like you get all of these team members, very intensive comprehensive geriatric assessment, assessing for everything, maybe taking hours or longer from this versus kind of more kind of usual care. But I do think like even in hospice care, like these things are important falls, function, incontinence, like it matters. So that little C comprehensive geriatric assessment still applies, it seems like. Would you agree with that?

Thiago 28:23

Yeah, and I think, I think it’s something that Eric mentioned before, that the systematic aspect of, you know, looking into all these things, I think it’s what sets the CGAs apart. At the end of the day, I agree that it’s providing good care. It didn’t have to be CGAs. You could do all of that and look into all these issues without it calling it the CGA because it’s good clinical care. But then doing it systematically will help you not forget about all these.

Eric Widera 29:01

And it takes time, right? Like systematic. This is not a 10, 15 minute appointment for one medical problem. Like this is. I hear you, Eric. 90 minutes. Which for primary care they don’t have 90 minutes, no way. So then the question I have is when we think about prioritization, like who should be getting it and where, given that, like the way the system is not resource unlimited, we have to think about the resources and where we should put in the resources.

And it reminds me of the JAGS article that just came out, Eric, which Diago did the editorial on money does matter, right? Where we put our resources matter. Do you mind, Eric, just describing in a quick nutshell, we won’t get too methodsy on this, but in a quick nutshell, what you were hoping, Hoping to achieve with this JAGS article?

Eric Wong 30:03

Oh, I was actually just going to talk about methods. I thought that’s what the article. I wasn’t sure after.

Eric Widera 30:11

Yeah, let’s talk about it. Because I got really confused. I read it like three times. Something about dominant versus dominated. Yeah, dominated. I’m all, we. Is this about something else than medicine domination?

Eric Wong 30:26

And I, I know I, I heard some feedback. I didn’t go to ags, but I heard that this was discussed at AGS in some way.

Alex 30:34

We discussed it in the reviewing for JAGS workshop. Yeah, it’s a great learning piece for participants.

Eric Wong 30:44

Eric, what were you. We’re just so grateful that JAGS decided to accept the paper. And I’m very grateful to the editors and also to Tiago and to SEI for writing that editorial, which I think helps people understand some of the limitations of the work we did and also contextualizes why this is important. So the whole premise of the study is there’s a shortage of geriatricians. And the shortage of geriatricians is in Canada, for sure. Canada, we have a very low ratio per older adult compared to, say, the US or the uk, where there’s an absolute larger geriatric workforce. So for Canada, this becomes a problem as our population ages.

So one of the things that we thought about is, well, we always try to recruit more geriatricians. And I think there’s a lot of people around the world who’ve tried different things to do that, but there are also some limits to that. So we’re seeing that even with trying to get people interested, we’re not seeing as many people applying. So then the other solution is how do we optimize, how do we make, make good use of the existing workforce of geriatricians in a population that’s going to age in the coming 10, 20 years? And so the question that we, or the direction that we wanted to take wasn’t quite about models of care. So, you know, in, you know, earlier we talked a lot about, you know, is it an ACE unit or is it a geriatric evaluation unit? We didn’t focus on that because, you know, that’s been looked at. But it’s also a little bit harder, right, because it’s context specific.

So instead we wanted to look at a more sort of a broader picture of just the healthcare settings where there’s a little bit more similarity across the world. When somebody’s in acute care, we kind of have a good sense of what those patients look like when they’re in rehab, which is a post acute setting. We have a good sense and some similarities. And then in the community setting, coming into an outpatient clinic to see a doctor. So we wanted to focus on the settings and try to answer that question. If we could choose one or two settings or if we didn’t have enough people to staff all the settings, which healthcare settings should we prioritize? Geriatricians first. And so there’s a two part to this.

And so there’s a part of the study which was a systematic review and a network analysis that one we are working on updating but we ended up doing the cost effectiveness first. But that study informed the cost effectiveness where we designed a model. So it’s a computer simulation model and we looked at older adults in Canada, in Ontario specifically, and we simulated what happened when we put geriatricians focus on different settings or different combination of settings and what the overall outcome is for the population.

Eric Widera 33:36

And is this geriatricians or comprehensive geriatric assessments?

Eric Wong 33:40

Yes, so that’s a great question. So it’s actually also specifically it’s a geriatrician led comprehensive geriatric assessment. Yes. So the question is a little bit different than should we do a CGA in which setting? We don’t quite answer that question. What we’re answering is because there’s specifically a shortage of geriatricians. Right. So we want to know where we should put the geriatricians to do the cga. Hopefully that clarifies a little bit about the research question.

Eric Widera 34:08

And the question is where? Inpatient rehab, outpatient, where should we target these geriatrician led comprehensive geriatric assessments?

Eric Wong 34:19

Yes, that’s correct. And so then we, you know, we ran the model and so yes, there’s different terms and I did, you know, after getting some feedback, this is where.

Eric Widera 34:30

It gets a little 50 shades of gray, which I was not expecting.

Eric Wong 34:34

I know, I know. And I heard about this, the domination.

Eric Widera 34:39

I thought that was. That should be your title, 50 Shades of Gray. Where to insert geriatricians.

Eric Wong 34:44

Oh yeah, that would be better.

Eric Widera 34:45

All right, tell our audience because they haven’t read the paper probably. What did you find?

Eric Wong 34:51

Right, so in terms of the strategies, when we rank the different strategies and the strategy is just when we do the geriatric assessments in a certain setting. So we focus on one setting or we deliver it in combination. So for example, it’s either acute care only, rehab only, or acute community clinics only. Or we might combine them, say acute care and rehab, acute care and community Clinics and so forth. And so what we found was that the, the best strategy, the optimal strategy, if there was a shortage, is to deliver the CJ in a combination of acute care and rehab. So to.

Eric Widera 35:24

And this is what you call the dominant strategy. Dominant, right.

Eric Wong 35:30

Yeah, yeah, we called it. We actually called it the undominated strategy.

Eric Widera 35:35

Undominated, yes.

Eric Wong 35:36

I know, I know.

Eric Widera 35:37

It’s very non. Fifty Shades strategy.

Eric Wong 35:42

Yes, it is a safe one. So that one. Because what happens is we rank all the strategies by lowest to highest cost. So the acute care and rehab strategy happened to be the lowest cost, and there wasn’t a strategy that had a lower cost that delivered greater benefit. So therefore it was undominated. But there was a second strategy later on, which is the triple strategy. So it’s delivering the CJ in the acute care, rehab and community settings. So everywhere, if local resources permit. And if you were able to do that, then it was still cost effective because although the cost was higher, the benefit was also higher.

And then we use a cost effectiveness threshold to determine whether a new intervention is cost effective. And it was below this threshold. And so for that, the term is cost effective. So that strategy is cost effective. The acute care and rehab is undominated.

Thiago 36:38

Okay.

Eric Widera 36:39

So if you’re resource limited, focused on acute care and rehab, if you got a lot of resources and geriatricians, you can focus on the spectrum, the whole spectrum. Is that right?

Eric Wong 36:52

Yes, yes.

Eric Widera 36:53

Is there any place where it doesn’t.

Eric Wong 36:56

Where it doesn’t work? No. So actually we also did a separate ranking. So traditionally, cost effectiveness analysis, we rank all of the strategies by lowest to highest cost and then we compare each pair wise. So we always compare it one at a time and usually compare it with the previous best strategy. But we decided to do an alternative ranking based on somebody on my PhD committee’s suggestion. And we ranked each strategy against usual care, and every single one of the strategies is either dominant or is cost effective. So you can choose to deliver the CJ in any of those combinations or individual settings, and it would still be better than usual care.

Eric Widera 37:38

Tiaga, you were at the editorial.

Thiago 37:40

Yeah, that’s right.

Eric Widera 37:41

Thoughts on that paper.

Thiago 37:43

First of all, I want to, you know, jokes apart, I want to congratulate Eric and the co authors on the work and kudos for jags for bringing something that’s not in our usual kind of comfort zone. But I think it’s really important that we think about clinical care in terms that are very important as well, economic aspects and so on. I think the main message in the editorial say and I discuss a little bit of the methods, some of the caveats and limitations that are important to our interpretation of the results. But I think the main message there is that this is very interesting and good study showing that geriatricians doing one thing, TGAs, are cost effective and pretty good.

Well, actually, geriatricians do a lot of other stuff in addition to CGAs, so it’s reasonable to infer that the cost effectiveness and benefit is even greater than what was described. So it’s important that we optimize resource allocation, but even more important that we get more geriatricians out there so everyone that needs them can receive their care.

Eric Widera 39:09

Eric, your big picture. What should we do with this study?

Eric Wong 39:14

When I try to explain this to clinical audiences, and I know it’s confusing to understand, but this is for an example of how you can use this information. Say there was a new hospital or a new community setting where you’re building a hospital, and in that local setting, in that local hospital, you have all of these. You’re building an acute care hospital. There’s maybe an attached rehab unit and then there’s an outpatient clinic.

And you’re the first geriatrician there. Right? You decided to apply and work there and you’re trying to figure out, well, I have all these places that I want to be, but there’s only one of me and I can’t work, you know, I can’t staff everything. And you try to recruit and you can maybe only recruit one person or maybe it’s just that, or just yourself. And so you have to decide, like, where am I going to focus my time? Which is a realistic scenario. Even in Ontario, where we’re at, and we have all these hospitals who further from the main city that are looking for geriatricians.

And so for them, you can use the studies to sort of say, okay, so if I don’t have enough geriatricians, I should really focus on the acute care side first and then spend some time at rehab. But that outpatient clinic, maybe we could wait until we have enough geriatricians to have them go there. And in the meantime, you can use, say, other providers. So there may be nurse practitioners, or in Ontario, we have family doctors who have care of the elderly training, so they could also staff the clinic settings until you have enough geriatricians to help out there.

Eric Widera 40:42

I love it. Well, I want to thank both of you for being on this podcast. But before we end, we’re going to go to Alex to do Billie Eilish. What song was it again? Something about aging getting older, getting older.

Alex 40:56

Getting older in this case from 18 to 19. I think she’s a little older than that now.

Eric Widera 41:02

I’m going to Wikipedia. I’ll let you know after the song. Let’s see.

Alex 41:16

(singing)

Eric Widera 42:40

Eric, Thiago, thanks for joining us on this podcast.

Eric Wong 42:43

Thank you.

Thiago 42:43

Thank you for having us.

Eric Widera 42:44

And we will have links to the JAGS article, to both the article and the editorial on our show notes and so please check it out. And thank you to all of our listeners for your continued support.

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Disclosures:
Moderators Drs. Widera and Smith have no relationships to disclose.  Guest Eric Wong and Thiago Silva have no relationships to disclose.

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