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Age and Ageing Advance Access originally published online on July 26, 2007
Age and Ageing 2007 36(6):670-675; doi:10.1093/ageing/afm089
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Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.

The older persons' assessment and liaison team ‘OPAL’: evaluation of comprehensive geriatric assessment in acute medical inpatients

D. Harari1,2,, F. C. Martin1,2, A. Buttery1, S. O'Neill1 and A. Hopper1

1 Department of Ageing and Health, Guys and St Thomas' NHS Foundation Trust, UK
2 Division of Health and Social Care Research, King's College, London, UK

Address correspondence to: D. Harari. Tel: 020 7188 2086; Fax: 020 7928 2339. Email: danielle.harari{at}kcl.ac.uk


   Abstract
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 Abstract
Introduction
 Methods
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 Discussion Points
 Conclusions
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 References
 
Background: reducing hospital length of stay (LOS) in older acute medical inpatients is a key productivity measure. Evidence-based predictors of greater LOS may be targeted through Comprehensive Geriatric Assessment (CGA).

Objective: evaluate a novel service model for CGA screening of older acute medical inpatients linked to geriatric intervention.

Setting: urban teaching hospital.

Subjects: acute medical inpatients aged 70+ years.

Intervention: multidisciplinary CGA screening of all acute medical admissions aged 70+ years leading to (a) rapid transfer to geriatric wards or (b) case-management on general medical wards by Older Persons Assessment and Liaison team (OPAL).

Methods: prospective pre-post comparison with statistical adjustment for baseline factors, and use of national benchmarking LOS data. Pre-OPAL (n = 46) and post-OPAL (n = 49) cohorts were similarly identified as high-risk by the CGA screening tool, but only post-OPAL patients received the intervention.

Results: pre-OPAL, 0% fallers versus 92% post-OPAL were specifically assessed and/or referred to a falls service post-discharge. Management of delirium, chronic pain, constipation, and urinary incontinence similarly improved. Over twice as many patients were transferred to geriatric wards, with mean days from admission to transfer falling from 10 to 3. Mean LOS fell by 4 days post-OPAL. Only the OPAL intervention was associated with LOS (P = 0.023) in multiple linear regression including case-mix variables (e.g. age, function, ‘geriatric giants’). Benchmarking data showed the LOS reduction to be greater than comparable hospitals.

Conclusion: CGA screening of acute medical inpatients leading to early geriatric intervention (ward-based case management, appropriate transfer to geriatric wards), improved clinical effectiveness and general hospital performance.

Keywords: older, length of stay, acute medicine, comprehensive geriatric assessment, elderly


   Introduction
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 Abstract
 Introduction
Methods
 Results
 Discussion Points
 Conclusions
 Key points
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 Abstract presentation
 References
 
Improving productivity of hospital services is a key policy requirement in the UK National Health Service (NHS). Hospital length of stay (LOS) is one of the most important productivity measures for acute adult medicine, where most patients are admitted non-electively. Predictors of greater LOS in older non-elective medical patients include reduced mobility, falls, cognitive impairment, malnutrition, incontinence, delirium, and living alone [1–4]. Short-term focus on the primary admission problem without addressing co-morbid chronic conditions is common, and may lead to inefficient hospital management and post-discharge care. For example, primary predictors of greater LOS in older people admitted with COPD exacerbations include number of co-morbidities, polypharmacy, and living alone [5].

Comprehensive Geriatric Assessment (CGA) broadens the care of older inpatients, but effectiveness relies on delivery method. CGA delivered by consultative geriatric teams on acute medical wards shows limited benefits, whilst improved outcomes (physical function, independent living) result from ‘hands-on’ CGA [6, 7]. Guideline distribution alone (e.g. delirium) is ineffective unless reinforced by teaching on the medical wards [8]. Follow-up is important [7]; outpatient CGA for older patients discharged from A&E resulted in fewer unplanned admissions and better physical and cognitive function at 6 months [9].

Health provision is financed on a non-fee-paying basis within the NHS. Although hospital services are funded nationally, they are commissioned through local NHS bodies (Primary Care Trusts), which are under continuing pressure to improve efficiency. Innovative new services are rarely funded unless they impact efficiency as well as quality of care.

We developed a novel service model for delivering early CGA to older medical inpatients leading to targeted geriatric intervention. High-risk patients were either rapidly transferred to geriatric wards or case managed on general medicine wards. The aim of this service model was to improve processes, and hence, quality of care in older acute medical inpatients with multiple co-morbidities, and thereby reduce their LOS. By processes of care, we mean getting the right patient (frail older person) to the right place (managed by specialist geriatric team) at the right time (early during the admission). This evaluation addresses the question ‘did early CGA intervention alter processes of care and LOS in high-risk medical inpatients aged 70+ years?’.


   Methods
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 Abstract
 Introduction
 Methods
Results
 Discussion Points
 Conclusions
 Key points
 Sources of funding
 Abstract presentation
 References
 
Setting
The study was conducted in a large urban teaching hospital, drawing on a local population of 0.5 million. Prior to the intervention, a minority of acutely hospitalised older medical patients were admitted directly to the specialist geriatric wards, usually because they had been referred by primary care physicians. The majority were managed by the acute general medicine service, unless subsequent geriatric consultation was requested. A substantial proportion of frail older patients were therefore managed by various teams without consistent care pathways. Initial scoping of patients aged 70+ years on general medical wards showed that geriatric referrals were frequently delayed until several days into the hospital admission.

The geriatric wards consisted of 72 beds with a case-mix of sub-acute medical and short-term rehabilitation patients, with ward-based teams of specialist doctors, nurses and therapists. Compared with the general medical wards, there was no greater or facilitated access to social care or community services with regards to discharge planning.

Intervention
The intervention was delivered by the Older Persons Assessment and Liaison (OPAL) team, consisting of elderly care nurse specialist, elderly care specialist physiotherapist, and half-time geriatrician. The nurse and physiotherapist screened all acute medical patients aged 70+ years within 24 h of admission (excluding weekends) using a CGA tool to identify moderate-high clinical risk. The one-page CGA screening tool used evidence-based predictors of prolonged length of stay [1, 2, 4], plus risk factors for poor outcomes in older people (social isolation, depression, falls, chronic pain, poor vision, weight loss)[4, 10–13]. Patients with >1 problem on screening received further OPAL involvement, with additional criteria being care home resident, previous elderly care inpatient, and 28-day readmission. Low-risk patients outside these criteria were tracked, and reassessed if still hospitalised after 4 days.

OPAL patients were discussed or reviewed by the geriatrician, and depending on clinical need, actions were: (i) rapid transfer to geriatric wards (ii) case management by OPAL on general medicine wards or (iii) facilitated discharge with referrals to appropriate geriatric clinics (e.g. CGA, falls, continence) and intermediate care schemes. In all these settings, CGA-related problems such as falls, incontinence and delirium were managed according to evidence-based protocols based on national guidance (NICE, British Geriatrics Society). As a guide to workload, during January 2005 (mid-intervention), OPAL screened 148 patients, of whom 100 (68%) were judged high-risk and managed accordingly.

Prior to starting OPAL, agreement was obtained from all general physicians that patients could be transferred to elderly care without first seeking their consent, and that OPAL could directly intervene on ‘geriatric’ issues (e.g. delirium, early rehabilitation, discharge planning, chronic disease management, elderly care (EC) outpatient follow-up for falls, continence etc.) when case-managing on their ward. An additional post-acute CGA clinic was created to see patients within 2 weeks of discharge.

Evaluation
The management imperatives of requiring change through rapid implementation ruled out a RCT to assess effectiveness. The efficacy of many of the specific geriatric interventions is already established. The process of getting the right people into the right pathways of care in timely fashion was the intended outcome, in the belief that this is likely associated with better clinical outcomes, and improved efficiency of inpatient care. The study did not seek to compare differences in clinical outcomes during or subsequent to the hospital stay, e.g. delirium resolution or falls rates, but rather, compared the proportion of individuals who were plugged into appropriate care pathways e.g. evaluation for falls risks leading to targeted interventions before and/or after discharge.

With this constraint, the alternative evaluation was a ‘before and after’ design with statistical adjustment for baseline differences. Before starting OPAL, the screening tool was used in consecutive acute medical admissions aged 70+ years over 1 month (August 2004). Forty-eight patients screened high-risk, but received no OPAL intervention—thus care reflected usual practice in managing complex older patients. ‘Pre-OPAL’ data were collected prospectively (daily notes review) by a geriatric team familiar with the project. In August 2005, ‘post-OPAL’ data were similarly collected, by a junior doctor unconnected with OPAL to reduce bias. Forty-nine patients screened high-risk and received OPAL intervention. Independent workers entered all data.

Benchmarking data used came from (i) Dr Foster Intelligence (www.drfoster.co.uk), a database based on Health Resource Groups (HRG) and LOS reported by Trusts and used by the NHS Institute for Innovation and Improvement (www.institute.nhs.uk) for comparing services nationally, and (ii) CHKS (www.CHKS.co.uk), a leading provider of healthcare information in the UK focussing on benchmarking and quality improvement.

Analyses
Pre-post bivariate comparisons used chi-square, t-test, and Mann–Whitney tests as appropriate. The association between LOS and the time period during which OPAL was implemented was examined using multiple linear regression to adjust for baseline factors. Two patients with LOS>100 days (102 and 149), both in pre-OPAL group, were excluded from the overall analysis to avoid outlier effect, but were included in a sensitivity analysis. Eight pre-OPAL and three post-OPAL patients died in hospital; they were excluded from the length of stay analysis to avoid confounding the evaluation of the proposition that OPAL shortened length of stay by facilitating hospital discharges.


   Results
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 Abstract
 Introduction
 Methods
 Results
Discussion Points
 Conclusions
 Key points
 Sources of funding
 Abstract presentation
 References
 
Table 1 compares case-mix and outcomes, and demonstrates clinical problems identified by the screening tool. There were some baseline case-mix differences. Pre-OPAL, few CGA problems identified by screening were addressed during admission or follow-up. For instance, 0% fallers pre-OPAL versus 92% post-OPAL were specifically assessed and/or referred onto a falls service post-discharge. Management of delirium, chronic pain, constipation, and urinary incontinence similarly improved as shown by inverse relative risks. Over twice as many patients were transferred to elderly care, with mean time from admission to transfer falling from 10 to 3 days. Readmission rates and referral rates to intermediate care did not differ.


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  		Table 1. Case-mix and outcomes comparing pre-OPAL to post-OPAL group

 
Mean LOS fell by 4 days post-OPAL. The association between length of stay and case-mix variables (age, gender, activities of daily living, mobility, delirium, dementia, incontinence, depression, falls, nutrition, pain, visual and hearing impairment, and ‘number of geriatric giants’), but not OPAL, was first analysed. The only trend association was ‘number of geriatric giants’ (P = 0.08). When OPAL intervention (as pre-post time period) was added, it became the only significant association with length of stay (P = 0.023), ‘geriatric giants’ being no longer related. Sensitivity analysis including the long stay outliers showed a mean of 18 days (SD 27.2) pre-OPAL and 11.4 days (SD 12.3) post-OPAL, with the adjusted linear regression association with OPAL persisting, but less robust (P = 0.053).

Hospital data showed mean LOS of 12.8 days for all medical admissions aged 70+ years, the year before OPAL, falling to 10.4 then 9.1 days the first and second years after OPAL. LOS in acute medicine corrected by HRG and compared with the NHS average for each HRG showed: 2003–04 +9,000 bed-days above NHS norms; 2004–05–10,000 bed-days below NHS norms; 2005–06–17,000 bed-days below NHS norms, approximately equivalent to a saving of 50 beds compared to average NHS practice. Length of stay of medical inpatients with the index frailty diagnosis of urinary tract infection was the lowest (5.4 days) compared to a benchmark comparison group of eight London teaching hospitals (range 7.2–12.0 days) (CHKS 2005). Data from Dr Foster Intelligence showed that the duration of stay in this hospital for non-elective admissions aged 75+ years with a diagnosis of urinary tract infection in 2003–04 was 13.2 days, falling to 7.6 days in 2005–06. In contrast, English averages for this period were 15.7 days (2003–04), and 14.8 days (2005–06) respectively.


   Discussion Points
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 Abstract
 Introduction
 Methods
 Results
 Discussion Points
Conclusions
 Key points
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 References
 
Pre-post comparison of a targeted early CGA service for older acute medical patients showed LOS reduction and evidence of improved practice, suggesting better clinical effectiveness and efficiency. This was supported by benchmarking data showing that the LOS reduction was greater than comparative acute hospitals.

We acknowledge the methodological limitations of this type of evaluation. The constraints of running the intervention as a service restricted the scope of the evaluation to short-term outcomes of clinical efficiency rather than longer-term outcomes. There could have been a trend change in LOS during this observational time period independently of OPAL. Clinical decision-making affects LOS, and perceived pressures on clinicians to shorten LOS in this hospital (like others) is a possible mechanism. There were, however, no systematic operational changes, such as intermediate or social care provision during this time period. National data suggest that the LOS reduction in medicine fell way beyond other hospitals. With stable readmission rates, it is unlikely that LOS reduction was obtained by clinically premature hospital discharge. The pre-OPAL group had a more adverse case-mix, which could be expected to be associated with greater LOS, and statistical adjustment may not have fully compensated for this. Observer bias was unlikely to affect LOS, and was otherwise minimised by having well-defined measures at data collection. Whilst an RCT may have avoided issues with baseline differences and time period effects, the OPAL case management approach was endeavouring to change practice making it impossible to avoid cross-contamination within a single site. A multicentre cluster RCT of this type of intervention would be an alternative if contextual factors specific to each site could be controlled for, and this would be valuable further research.

Future work could also link specific patient outcomes to the intervention, which fell beyond the scope of the present study. A recent German RCT of geriatric consultation versus usual non-specialist care in older hospitalised patients failed to show an impact on 12 month outcomes of death and institutionalisation [14], raising the possibility that had short-term outcomes been measured, other benefits may have been identified [15].

Early transfers directed by OPAL increased activity and acuity of the case-mix on the geriatric wards, and presumably reduced the co-morbidity profile in case-managed patients remaining on general medical wards. The associated LOS reduction suggests this early geriatric involvement with complex patients improves overall efficiency of hospital care, with favourable financial implications. OPAL cost £ 170K per annum (2004–05), initially funded by reinvesting part of approximately £ 1 million savings from closing a general medicine ward. The number of medical beds in this hospital fell from 340 in 2002 to 230 in 2006. In the winter of 2003–04 the hospital had a large number of medical outliers, but in winter 2005–06, there was not a single outlier despite increased activity and reduced beds. A practical goal of this evaluation was to secure continued funding based on clinical efficiency measures, and to demonstrate generalisability within the British NHS, where access to inpatient geriatric beds exits. The OPAL skill-set and processes have proved transferable; to date, three other teaching hospitals have adopted and resourced the service model.

OPAL combined rapid transfer to geriatric wards with case management on acute medical wards; there is no similar published intervention, but these components have been investigated. Paradoxically in the UK, where the geriatric speciality is well established, there has been little research at level of evidence 1 or 2 in this area; the following evidence-base comes from outside Europe. One RCT compared acute older medical patients admitted to geriatric versus general medical wards and found a shorter length of stay (5.9 versus 7.3 days) with no increased readmissions and more direct-to-home discharges [16]. Another found that admitting acute medical patients to geriatric wards improved processes of care, e.g. implementing nursing care plans, promoting independence, early physiotherapy [17]. Unselected age-based medical admissions to geriatric wards showed no benefits however, emphasising the importance of targeting patients for specialist geriatric care [18, 19.

Geriatric case-management on acute medical wards and the impact on length of stay was described almost 30 years ago in a UK publication [20], but the model has not been generally adopted within the NHS, and more recent studies are again from outside the UK. One RCT showed that case-management with goal-setting multidisciplinary teams working alongside acute medical ward teams reduced LOS (non-significantly) and in-hospital functional decline in older people [21]. A US geriatrician/social worker team following patients from A&E to discharge slightly reduced LOS but significantly lowered hospitalisation costs, mainly through less diagnostics and pharmacy use [22]. Another US RCT evaluated a multidisciplinary team doing daily visits to improve care in acute medical inpatients of all ages, and showed significantly reduced LOS and hospital costs [23]. Although the OPAL model risks down-skilling by promptly transferring the more complex patients, case-management through medical ward staff may also increase their skills in managing frail older people. The broader view is that this service model took the skills and perspectives of geriatric medicine into acute medicine, rather than the converse, now so prevalent in the UK.


   Conclusions
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion Points
 Conclusions
Key points
 Sources of funding
 Abstract presentation
 References
 
CGA screening of acute medical inpatients by a specialist team leading to early intervention improved clinical effectiveness and general hospital performance. This intervention effectively targeted a large population with small resources, and is generalisable within health systems where there are geriatric beds, multidisciplinary expertise, and outpatient capacity.


   Key points
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion Points
 Conclusions
 Key points
Sources of funding
 Abstract presentation
 References
 

  • Reducing hospital LOS for older acute medical patients is a key health policy requirement and productivity measure.
  • Evidence-based predictors of prolonged LOS may be targeted by CGA.
  • Case-finding high-risk older acute medicine inpatients by CGA screening linked to geriatric intervention improved clinical effectiveness and reduced LOS.


   Sources of funding
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion Points
 Conclusions
 Key points
 Sources of funding
Abstract presentation
 References
 
No external funding


   Abstract presentation
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion Points
 Conclusions
 Key points
 Sources of funding
 Abstract presentation
References
 
British Geriatrics Society Scientific Meeting April 2006


   Conflicts of interest
 
The authors have no conflicts of interest


   Acknowledgements
 
We are grateful to Dr Rory McGovern and Louise Briggs for early scoping and development work, Dr Shillo Pallai for assistance with data collection, and Fionna Martin and James Crane for data entry.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion Points
 Conclusions
 Key points
 Sources of funding
 Abstract presentation
 References
 

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Received 13 February 2007; accepted in revised form 16 May 2007.


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