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Age and Ageing Advance Access published online on August 14, 2008
Age and Ageing, doi:10.1093/ageing/afn161
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Copyright © The Author 2008. Published by Oxford University Press on behalf of the British Geriatrics Society.

Geriatric assessment in general practice using a screening instrument: is it worth the effort? Results of a South Tyrol Study

Giuliano Piccoliori, Elena Gerolimon and Heinz-Harald Abholz

Universitätsklinikum Düsseldorf, Abteilung für Allgemeinmedizin, Geb. 14.97, Moorenstr. 5, 40225 Düsseldorf, Germany

Address correspondence to: Heinz-Harald Abholz. Tel: (+49)-211-8117771. Email: abholz{at}med.uni-duesseldorf.de


   Abstract
Top
 Abstract
Methods
 Results
 One-year follow-up
 Discussion
 Key points
 Conflicting interests
 Ethical approval
 References
 
Background: geriatric assessment is a well-established instrument to improve the care of the elderly, but little is known about it in general practice although patients often are known for years.

Methods: we used STEP-assessment, an instrument developed by European General Practitioners (GPs), which identifies only problems that can be improved; 37 questions had to be answered by the patient and 4 tests had to be done by the GP. Additionally in the study, GP and patient had to indicate separately which of the problems were seen as relevant and what both accepted to do for improvement. A year later, participating GPs were asked by a not-announced questionnaire to report on improvements and reasons for failure.

Results: of the 220 eligible GPs, 45 enrolled a random sample of 894 patients (average age 77 years). In all 7.8 out of 32 possible problems per patient were found. Of those, 1.4 problems were not known to the GP. More than two-thirds of the ‘new problems’ are perceived as relevant by GP, patient or by both. GPs assessed medical problems and patients assessed social/psychological problems as more relevant. The length and quality of the relationship with the patient was reflected in the number of new problems, with fewer new problems in those well-known. A year later, GPs had offered treatment for 47% of the newly diagnosed problems, with a success-rate of 81%.

Conclusion: geriatric screening can detect unidentified problems in general practice. Once detected and dealt with, a high proportion of the undetected problems showed improvement. GPs focussed more on medical, while patients more on psychosocial issues. To increase the outcome of screening, it is necessary to discuss the relevance assessed by the patient.

Keywords: general practice, elderly, geriatric assessment, screening, follow-up study, elderly

Assessment of older people using screening instruments has been undertaken for over 30 years [1–4], but its value in general practice remains uncertain [5–12]. Some studies report new diagnoses discovered through screening [13], although in a long-term medical relationship general practitioners (GPs) may already know about important conditions without screening.

We aimed to determine the following.

(1) If geriatric assessment could detect problems unknown in general practice.
(2) If previously unknown problems were seen as important by GPs and patients.
(3) Whether the length of the GP–patient relationship influenced the number of problems identified.
(4) The consequences for the patient in identifying problems.


   Methods
Top
 Abstract
 Methods
Results
 One-year follow-up
 Discussion
 Key points
 Conflicting interests
 Ethical approval
 References
 
As many as 220 GPs who had been in practice longer than 6 years were asked by letter to take part in this study in bilingual (German/Italian) South Tyrol, Italy. They were asked to identify 30 patients randomly from their list of patients aged 70 years and older, after eliminating those fulfilling the exclusion criteria: inability to speak Italian/German; life expectancy of less than a year; intellectual inability to answer the questionnaire or to come into the surgery (housebound), being a patient for less than 1 year.

Patients completed the STEP assessment, and then talked with doctor about the relevance of what was found. The STEP screening instrument [14–17] was developed by a group of GPs from seven European countries and consists of a 37-item questionnaire (with 32 clinical items) for the patient, and a shorter questionnaire for the GP who, additionally, had to examine cognitive function, blood pressure, heart rate, mobility, balance and blood sugar. All items in the STEP assessment consider features with potential for improvement.

In addition to the STEP instrument, GPs asked patients, which of the ‘problems’ they considered as ‘relevant’. GP did the same from his/her point of view. Relevant was defined as ‘something has to be done and can be done’.

GP and patient then discussed the newly found problems and together decided on further intervention.

We did not inform the participating GPs about a planned follow-up. After 1 year, we contacted all participating GPs asking them to fill in a questionnaire for each patient in whom they identified a ‘new and relevant’ problem. We asked how many of the problems were dealt with and how they would assess the success of the interventions. Open answers were allowed concerning reasons for not treating a problem or if they felt the intervention had not been successful. ‘Success’ was defined as a ‘clinically relevant change or an improvement in the quality of life for the patient’. Responses were read by two of us (GP, HHA) and analysed independently using content analysis without prefixed categories according to Mayering [18]. In case of different interpretations, the text was read again to reach a consensus.


   Results
Top
 Abstract
 Methods
 Results
One-year follow-up
 Discussion
 Key points
 Conflicting interests
 Ethical approval
 References
 
Of the 220 eligible GPs, 45 (40 males and 5 females) participated. They were in practice for a mean of 16 (SD 8) years. The composition of the group based on age, sex, time in practice and first language was comparable to the population of doctors in the region.

They returned an average of 20 questionnaires (5 from 1 surgery, 11–13 from 2, 15–20 from 13 and 20–29 patients from 29 surgeries). In all, 894 patients between 70 and 98 years participated; 39% were men [average age 76.8 (SD 5.4)] and 61% women [average age 77.6 (SD 5.5)].

Problems
Of the 32 clinical items in the questionnaire, women had on average 8.6 problems (SD 4.3) and men 6.7 problems (SD 4). Of these problems, mean 1.5 (17%) in women and 1.1 (17%) in men were new to the GP.

In Table 1, ‘problems’, ‘new problems’, ‘new problems relevant for the GP alone or both GP and patient’ and ‘new problems being relevant for the patient alone or both patient and GP’ are given.


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  		Table 1. Problems, new problems and relevance as seen by GP and patient (n = 894)

 
Pains of the joints, problems with teeth, problems in orientation as an indication for dementia, missing of vaccination against influenza and sleeping problems were the most often mentioned problems. The ranking of ‘new problems’ for the GP is different from the ranking of ‘problems’ themselves. As an example, financial problems, alcohol and falls are relatively rare but rank high among relevant problems for the GP—between 22% and 35% of these problems were not known to the GP.

The relevance of a ‘new problem’
For half of newly found problems, GP and patients agreed in their view about the relevance of the problem (24% relevant for both, respectively; 27% not relevant for both). Less than a fifth of all newly found problems were relevant for the GP only (18%), while a third of all newly found problems were relevant only for the patient (31%) (summary data not shown in tables).

In Table 2, the most relevant new problems for the GP, the patient and for both are shown. Some problems, mostly medically defined, were often seen as relevant by the GP, but not by the patient (like hypertension). Problems with teeth, sleep, mood, incontinence, joint pains, constipation and social and financial problems were more often seen as relevant problems by the patient than the GP.


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  		Table 2. Relevance of new problems—different points of view from GP and patient

 
Outcome of screening
Of the problems identified by the STEP assessment, 17% were new to the GP, but of these newly found problems only 42% were perceived as relevant by the GP (i.e. 7% were new and relevant). From the patient's perspective, 9% of the problems were new and perceived as relevant and 12% of problems were new and were of relevance to either the GP or the patient or both.

Association with ‘knowing each other’
Length of GP–patient relationship was associated with number of problems found: 14% newly found problems in those knowing each other for more than 8 years versus 26% knowing each other for less than 8 years (p\lt 0.001), although patients known for longer had the same number of total problems on average as patients who were known for less time. Findings were similar for a 2-year cut-off.


   One-year follow-up
Top
 Abstract
 Methods
 Results
 One-year follow-up
Discussion
 Key points
 Conflicting interests
 Ethical approval
 References
 
In spite of three reminders, only 23 of the 45 GPs answered our follow-up questionnaire after 1 year. The group of doctors answering was comparable to those not answering by sex, age and time in practice. The 23 GPs filled in questionnaires for 498 patients of the total number of 894 patients. These 498 patients had 657 newly found and relevant problems as seen by the doctor, the patient or both.

Approach to the newly found problems
Of all newly found and relevant problems, 47% of problems were dealt with and in 78% of these problems the intervention was documented; 56% changed or started medication; 23% had further diagnostic procedures and/or referral to a specialist. In 21% it was more consultations for advice/support.

Of the newly found and relevant problems, 53% did not initiate any sort of intervention for which GPs only gave reasons in 51% of the cases. If they explained their withholding of interventions, in 84% of these cases they felt that treatment was not necessary or was very unlikely to lead to any improvement. In 16% of these cases the patient refused a proposed intervention.

When grouping the more detailed data from Table 3 under headings, we found that for ‘somatic problems’ in 63% an intervention was started with an 84% success-rate.

But in case of ‘functional disability problems’, ‘mental health problems’ and ‘lack of social support/social problems’ only in 39, 30 and 32% of the problems, respectively, an intervention was started with success rates of 84, 64 and 72%, respectively.

Reasons for no success were given in only 31% of the problems. When given, the patient was mostly seen as the explanation for refusal or non-compliance.


   Discussion
Top
 Abstract
 Methods
 Results
 One-year follow-up
 Discussion
Key points
 Conflicting interests
 Ethical approval
 References
 


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  		Table 3. Approach to ‘newly found and relevant problems’—GPs responses 1 year after the screening, grouped according to the type of problem (N = 697 newly found and relevant problems in 498 patients)

 
We found that GPs who have been in their rural or small town surgeries for an average of 16 years and who work in a gate-keeping system, still found new problems, diseases and disabilities in their populations of older people, when using screening assessment. Of the problems, 17% were ‘new problems’, of which two thirds (12%) were relevant for the GP, the patient or both. Because STEP only identifies problems that can be treated—with at least a small chance of success—this is a significant rate. The better or the longer the patient is known to the GP, the fewer new problems can be identified. This supports the idea that in general practice continuity promotes better care.

We also found that GPs and patients quite often assess problems differently. Medical problems are more often seen as relevant by the GP; non-medical problems are more often seen as relevant by the patient. This highlights the importance of effective communication between the patient and GP about identified problems to raise compliance with any agreed intervention. Interestingly, the stated success rates of interventions were very high (80%).

It is difficult to compare our study with previous studies. Most of these studies took place many years ago, and in countries with different health care systems, usually involving much smaller groups of patients. In addition, all studies about geriatric assessments used different screening instruments.

The only comparable study was by Junius [16] who also used STEP in German general practice. But her study was done in a very small group of patients (n = 62) from 10 surgeries. Later she performed another study with a larger group of patients (n = 466) from 67 German GPs (not published). She found on average of 4 new problems/per patient, compared to 1.7 new problems found in our study.

All the other studies that have undertaken geriatric assessment in hospitals or in out-patient departments [19–24] and having an additional intervention (e.g. home visits) are otherwise not comparable with our study [25–28].

A weakness of our study is that we got only half the doctors answering in the follow-up. A selection of the most active, also active in treating ‘newly found problems’, is possible. But even if the other half of doctors had not commenced treatment at all, the rate of successful treatment, change of life-style or social support would be large enough to justify screening.

We conclude that screening, using STEP, is worthwhile. It is important to agree with the patient which of the revealed problems he/she sees as relevant. The finding of new problems, disabilities or diseases is not, in itself, a measure of success. Success needs two further criteria: firstly, the treatment to be started and secondly, the treatment to be effective. Most studies that used these criteria have been unable to show such success [29, 30]. We have shown this at least according to the doctors’ point of view.


   Key points
Top
 Abstract
 Methods
 Results
 One-year follow-up
 Discussion
 Key points
Conflicting interests
 Ethical approval
 References
 

  • Geriatric assessment as a screening-instrument is able to identify a number of important illnesses, diseases and disabilities—even in general practice where patients are usually quite well known.
  • The longer a patient is known, the fewer new problems can be identified by screening.
  • Patients and doctors differ remarkably in which of the newly identified health problems they see as important and worth the effort to intervene.
  • An astonishingly high percentage of newly identified problems were approached by doctor and patient and were seen as being ‘treated’ successfully 1 year after the screening.


   Conflicting interests
Top
 Abstract
 Methods
 Results
 One-year follow-up
 Discussion
 Key points
 Conflicting interests
Ethical approval
 References
 
No conflict of interest declared for all authors.


   Ethical approval
Top
 Abstract
 Methods
 Results
 One-year follow-up
 Discussion
 Key points
 Conflicting interests
 Ethical approval
References
 
In South Tyrol, Italy, ethical approval is not necessary for such a study, where the only intervention is to make care better, but not by using new treatments or medications. The necessary use of only pseudonomised (acronomised) data was regarded.


   References
Top
 Abstract
 Methods
 Results
 One-year follow-up
 Discussion
 Key points
 Conflicting interests
 Ethical approval
 References
 

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Received 7 June 2007; accepted in revised form 3 March 2008.


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