Treatment in a Geriatric Day Hospital improve individualized outcome measures using Goal Attainment Scaling

This prospective cohort study took place in the GDH at the Nova Scotia Health Authority (Central Zone) in Halifax, Canada. The GDH follows the traditional day hospital model of care and assesses over 200 patients annually. The average length of enrollment is 11 visits (Canadian national average 18) [7] with typically 2 visits/week. The program runs daily from Monday to Thursday with four patient cohorts attending Monday and Wednesday (mornings or afternoons), or Tuesday and Thursday (mornings or afternoons). Daily census rates average 20 patients. The program is staffed by two separate but overlapping teams each consisting of a physician, a registered nurse, a physical therapist, an occupational therapist and a social worker. Baseline comprehensive multidisciplinary assessments examine cognition, mobility, function, co-morbidities, symptom control and polypharmacy. In addition observer-rated GAS is completed as part of routine care by GDH team members for all patients at admission and discharge.

A total of 490 outpatients were serially admitted to the GDH between December 2008 and June 2011 (Fig. 1). The data of 21 patients were excluded from this study due to abstraction errors (N = 7) or missing admission GAS scores (N = 14). Of the remaining 469 patients, 25 had no discharge GAS data. Starting September 2010 all admitted patients were asked to receive a follow-up phone call 6 months following discharge (n = 206). Consent was obtained from 129 patients (henceforth referred to as the 6 month cohort). Among the 77 who did not consent, 24 declined participation, 14 withdrew from GDH program before consenting, 10 were admitted to hospital or other service before consenting, seven did not end up attending the GDH program, three did not provide a reason, 14 were excluded for other reasons, and for five we missed the opportunity to obtain consent.

Among the 129 who consented, eight did not complete the GDH program and three did not participate in the 6-month follow up phone call leaving a total of 118 patients included in the 6-months follow up analyses (Fig. 1). Follow up GAS data were obtained by a research nurse using a standardized and validated telephone interview [3] with either the patient or their caregiver (in cases where the patient was deceased or cognitive impairment was noted during GDH admission). The 6-month follow-up period was selected with the objective of allowing enough time to lapse to show change, but not so much time that new health issues may confound the score [3]. Ethics approval for the study was obtained from the Capital Health Research Ethics Board.

GAS is an individualized, observer-rated, outcome measure designed to capture patient-centred treatment effects on a five-point scale [8]. At admission, problem areas specific to each patient were identified by the GDH multidisciplinary team and set as goals. The team aims to assign goals for the patients that are the most pertinent to the patient (i.e. reason for referral or of concern to the patient), measurable and realistic to achieve during the GDH. Typically 1–3 goals are assigned per patient; for additional areas of concern for the patients, the team does not assign goal levels to these domains but monitors them. The GDH team groups the goals into four general domains (mobility, function, cognition, other). For goals in the “other” domain, the research team reviewed all goals and grouped them by consensus as social, home support, and medication. Therefore for purposes of analyses, the goals set at admission were grouped into six domains including mobility, cognition, falls, medication optimization, home supports and social issues.

The admission status for each goal was captured descriptively and set at “0” on the scale. Plausible outcome levels representing degrees of improvement or worsening were documented and designated to one of the four remaining levels of the scale: (i.e., −2 = very much worse than baseline; −1 = somewhat worse; +1 = somewhat better; and +2 = very much better). For example, the GDH team set a mobility goal for patient Y, who reported having one fall per week and difficulty with stairs (admission status = 0). The desired outcomes for this patient were identified as having less than one fall/week and following the recommendations of the GDH team regarding stairs (+1 “somewhat better”) and having no further falls and no difficulty with stairs (+2 “much better”). At GDH discharge the goals were reviewed by the GDH team and the level of goal attainment (i.e., the score) was determined by the extent to which the current status conformed to one of the levels defined at admission (no evident change from baseline was scored as 0). During the 6 month follow up telephone interview, the research nurse enquired about the current level of functioning for each original goal and then scored goal attainment in accordance with the scale defined at admission. The research nurse was blinded to the goal attainment scores assigned at discharge.

GAS scores are standardized by a summary formula that adjusts for varying numbers of goals per patient and varying levels of attainment per goal:

where x_i is the individual attainment level (between −2 and +2) and w_i is the weight of the goal (in this study all goals were weighted as 1). The formula results in a score of 50 when all goals remain at 0 (as is the case at admission when goals are first set), <50 when there is net worsening across goals, and >50 when there is net improvement across goals. An overall GAS score (Total GAS) was calculated for each patient, as well as scores for goals by domain.

Patients attending the GDH routinely complete a battery of standardized, validated psychometric measures upon admission and discharge (Table 1). The Mini-Mental State Examination (MMSE) [14] is a brief, 20-item instrument that measures orientation to time and place, immediate recall, short-term memory, calculation, language and constructive ability. The maximum obtainable score is 30 and the published minimum detectable change (MDC) is 3 points [15, 16]. The BERG Balance Scale (BBS) [17] is a 14-item functional measure of balance impairment in ambulatory older individuals, with an MDC of 5–7 points depending on baseline [18]. The Performance Oriented Mobility Assessment (POMA) [19] is a widely-used assessment of mobility, balance and gait in older populations. The maximum score is 28 (12 points for the gait component and 16 points for the balance component) and the MDC is 5 points [20]. The Timed Up and Go (TUG) [21] is an evaluation of transfers and ambulation with an MDC of 4 seconds [22, 23]. The Elderly Mobility Scale (EMS) [23] assesses mobility in 7 dimensions of functional performance including locomotion, balance and key position changes for a total score of 20. Its MDC is 3 points [24]. The Lawton Brody Instrumental Activities of Daily Living scale [25] is a validated assessment of function in older adults with an MDC of 1 point [26].

Frailty at admission was operationalized using the deficit accumulation approach. A frailty index was constructed following a standard methodology [27] by combining 37 measures collected as a part of the standard assessment upon admission to the GDH [(e.g. weight loss, mobility impairment, and osteoporosis). Each of the included variables was coded to represent the presence or the absence of a health problem. A frailty index score, ranging from 0 to 1, was calculated for each patient by dividing the number of health problems the patient had by 37; if a patient had X missing data then the denominator was adjusted (i.e., 37-X). The characteristics of the frailty index constructed for this study were similar to those from other clinical databases. The frailty index is designed to be used as a continuous measure, however, cut points have been suggested to identify frailty groups: 0 to ≤ .10 non frail, >.10 to ≤ .21 vulnerable, >.21 to <0.45, mildly/moderately frail, ≥0.45 severely frail [28].

Statistical analyses were carried out using IBM SPSS Statistics (version 22) and R Studio (version 0.98.1103). Descriptive statistics and comparisons between groups (e.g., those in the main cohort who were followed up at 6-months vs. those who were not and those who improved on GAS vs. those who did not) were carried out with t-tests and Chi squared analyses. Changes in psychometric measures (admission to discharge) and GAS (admission, discharge, 6 months follow up) were examined using repeated measures ANOVA. The responsiveness of each measure was compared by calculating the standardized response mean (mean change divided by the standard deviation of the change scores) [29] and the proportion of patients who improved by at least the established MDC values (note that for GAS any improvement is considered clinical significant and was recorded as MDC). We performed univariate logistic regression analyses and one way ANOVAs to determine the relationship between baseline characteristics and improvement on Total GAS at discharge and 6 months.