Maly, Rose C. Leake, Barbara. Frank, Janet C. DiMatteo, M Robin. Reuben, David B.
Title Implementation of consultative geriatric recommendations: the role of patient-primary care physician concordance.
Source Journal of the American Geriatrics Society. 50(8):1372-80, 2002 Aug.
Abstract OBJECTIVES: To examine the effect on primary care physicians’ implementation and their patients’ adherence behaviors of patient-physician concordance about recommended geriatric health care. DESIGN: Case-series, independent interviews of patients and their physicians about their perceptions of the patients’ health and the comprehensive geriatric assessment (CGA). SETTING: Community. PARTICIPANTS: Community-dwelling older patients (n = 111) who received consultative outpatient CGA and their primary care physicians. MEASUREMENTS: Concordance variables were generated using physician and patient responses to 10 questions on health- and CGA-related perceptions. An overall concordance score was generated by summing the total number of items on which patients and physicians agreed. Measures of the two dependent variables (physician implementation of and patient adherence to CGA recommendations) were by self-report. RESULTS: In multiple logistic regression analyses, overall concordance between patient and physician proved to be a significant and powerful predictor of physician implementation of (adjusted odds ratio (OR) = 2.7, 95% confidence interval (CI) = 1.6-4.6, P <.001) and patient adherence to (OR = 2.7, 95% CI = 1.7-4.2, P <.001) CGA recommendations, controlling for patient and physician gender and age, patients' functional status, duration of the patient-physician relationship, and frequency of visits in the previous year. Further analysis revealed that mutual patient-physician concordance on health-related perceptions was a significant predictor of these outcomes, whereas individual patient or physician perceptions were not. CONCLUSION: Concordance between older patients and their primary care physicians is a powerful predictor of physician implementation of and patient adherence to outpatient consultative CGA recommendations. Future research should focus on ways physicians can assess and negotiate patient-physician agreement on geriatric healthcare recommendations.

Unique Identifier 10078887

Authors Full Name Reuben, D B. Frank, J C. Hirsch, S H. McGuigan, K A. Maly, R C.
Institution Multicampus Program in Geriatric Medicine and Gerontology, UCLA School of Medicine, Los Angeles, CA 90095-1687, USA.
Title A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations.[see comment].
Comments Comment in: J Am Geriatr Soc. 1999 Mar;47(3):371-2; PMID: 10078904
Source Journal of the American Geriatrics Society. 47(3):269-76, 1999 Mar.
Abstract BACKGROUND: Although comprehensive geriatric assessment (CGA) has been demonstrated to confer health benefits in some settings, its value in outpatient or office settings is uncertain. OBJECTIVE: To assess the effectiveness of outpatient CGA consultation coupled with an adherence intervention on 15-month health outcomes. DESIGN: A randomized controlled trial. SETTING: Community-based sites. PATIENTS: 363 community-dwelling older persons who had failed a screen for at least one of four conditions (falls, urinary incontinence, depressive symptoms, or functional impairment) INTERVENTION: A single outpatient CGA consultation coupled with an intervention to improve primary care physician and patient adherence with CGA recommendations. MEASUREMENTS: Medical Outcomes Study Short Form-36 (MOS SF-36), restricted activity and bed days, Physical Performance Test, NIA lower-extremity battery. RESULTS: In complete case analysis (excluding the five control group subjects who died during the follow-up period), the adjusted difference in change scores (4.69 points) for physical functioning between treatment and control groups indicated a significant benefit of treatment (P = .021). Similar benefits were demonstrated for number of restricted activity days and MOS SF-36 energy/fatigue, social functioning, and physical health summary scales. In analyses assigning scores of 0 to those who died, these benefits were greater, and significant benefits for the Physical Performance Test and MOS SF-36 emotional/well being, pain, and mental health summary scales were also demonstrated. CONCLUSIONS: A single outpatient comprehensive geriatric assessment coupled with an adherence intervention can prevent functional and health-related quality-of-life decline among community-dwelling older persons who have specific geriatric conditions.

Reuben, D B. Maly, R C. Hirsch, S H. Frank, J C. Oakes, A M. Siu, A L. Hays, R D.
Institution Multicampus Program in Geriatric Medicine and Gerontology, UCLA School of Medicine, Los Angeles, California 90095-1687, USA.
Title Physician implementation of and patient adherence to recommendations from comprehensive geriatric assessment.[see comment].
Comments Comment in: Am J Med. 1996 Apr;100(4):383-5; PMID: 8610723
Source American Journal of Medicine. 100(4):444-51, 1996 Apr.
Abstract PURPOSE: The goals of this study were to develop and determine the feasibility of interventions designed to increase both primary care physician implementation of and patient adherence to recommendations from ambulatory-based consultative comprehensive geriatric assessment (CGA), and to identify sociodemographic and intervention-related predictors of physician and patient adherence. PATIENTS AND METHODS: One hundred thirty-nine community-dwelling older persons who failed a screen for functional impairment, depressive symptoms, falls, or urinary incontinence received outpatient CGA consultation. These patients and the 115 physicians who provided primary care for them received one of three adherence interventions, each of which had a physician education component and a patient education and empowerment component. Recommendations were classified as physician-initiated or self-care and as "major" or "minor"; one was deemed "most important". Adherence rates were determined on the basis of face-to-face interviews with patients. RESULTS: Based on 528 recommendations for 139 subjects, physician implementation of "most important" recommendations was 83% and of major recommendations was 78.5%. Patient adherence with physician-initiated "most important" and "major" recommendations were 81.8% and 78.8% respectively. In multivariate models, only the status of the recommendation of "most important" (odds ratio 2.4, 95% CI [confidence interval] 1.3 to 4.5) and health maintenance organization (HMO) status of the patient (odds ratio 2.1, 95% CI 1.3 to 3.6) remained significant in predicting physician implementation. The logistic model predicting patient adherence to physician-initiated recommendations included male patient gender (odds ratio 3.1, 95% CI 1.3 to 7.0), the status of the recommendation of "most important" (odds ratio 1.9, 95% CI 1.0 to 3.8), total number of recommendations (odds ratio 0.7, 95% CI 0.5 to 0.9), and total number of problems identified by CGA (odds ratio 1.8, 95% CI 1.2 to 2.7). CONCLUSIONS: These findings indicate that relatively modest interventions strategies are feasible and lead to high levels of physician implementation of and patient adherence to physician-initiated CGA recommendations. These interventions appear to be particularly effective in HMO patients and for recommendations that were deemed to be "most important".