The care of frail older people, and the role of the Comprehensive Geriatric Assessment (Refs: NIC-383324-D6B8T, previously HESR019)

The Nuffield Trust’s overarching purpose is to help provide objective research and analysis that boosts the quality of health policy and practice, and ultimately improves the health and health care of people in the UK. The Nuffield Trust are an independent research group overseen by a board of Trustees including a number of senior NHS clinicians, managers and academics. The Nuffield Trust undertake work for the public good and within a research governance framework.

In these studies Nuffield Trust are seeking to improve the NHS’s ability to identify and implement good practice in terms of efficient and effective health care for patients.

Data from NHS Digital has been received and processed for the following projects:

• Surveillance of outcomes and health service use for frail older people. This work is aiming to develop better indicators to identify good quality provision of care for older people. The focus of the first is to help the NHS spot effective care via innovative use of linked person-level datasets. The Nuffield Trust will try to identify areas of the country that are caring well for those aged over 65 with long term conditions and multiple co-morbidities. The project will develop new measures that make use of care pathways to provide a more sophisticated classification of patient types. The metrics will then be applied to the whole country to identify areas in England where the care pathways seem better than expected in terms of promoting better quality of care for older people. These areas will then be explored using qualitative methods to assess the nature of the successful service.

• An evaluation of the Comprehensive Geriatric Assessment (CGA) – Nuffield Trust were co-applicants with the University of Newcastle, and the work funded by the NIHR. The CGA is a multidisciplinary process designed to assess a frail older person’s medical conditions, mental health, functional capacity and social circumstances. However information is lacking on the types of patients that might benefit the most. The aim of this work is to describe existing models of care and to validate tools to deliver CGA on a hospital wide basis. No record level data is provided to the University of Newcastle.

Older people are the major users of acute hospitals, yet there is a growing perception that care for older people is sub-optimal (Patient’s Association report 2011, Health Service Ombudsman’s report 2011). Comprehensive geriatric assessment (CGA) is defined as ‘a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail older person in order to develop a coordinated and integrated plan for treatment and long-term follow-up’. CGA improves outcomes for frail older people, including survival, cognition, quality of life and reduced length of stay, readmission rates, long term care use and costs.

CGA is the accepted gold standard method of caring for frail older people in hospital, documented in numerous randomised controlled trials and associated systematic reviews and meta-analyses. It was unclear, however, which types of patients benefit most and how CGA should best be targeted to achieve maximum impact.

In addition, individual patient characteristics and frailty markers that best predict improved outcomes from CGA is unknown. It is essential that factors identifying benefit can be derived from routine hospital data to facilitate service level evaluation of health outcomes and health and social care costs, but the feasibility of this is unknown. The number of people who might benefit from CGA is estimated to be between 15-50% of older inpatients, based on the prevalence of cognitive dysfunction as a marker for frailty.

This work would therefore explore clinical markers of frailty that are quick and simple to use, and can map to larger datasets from a health and social care perspective. This in turn would provide accurate data on the numbers involved in different hospital settings which are required to plan and resource appropriate models of service for the projected increasing admissions of older people to hospital.

Both studies would rely on analysis of older individuals who are likely to be frail and have multiple long term conditions. Information on mortality will be important for such a group, as death rates for specific subgroups are likely to be high.

PROMs data were requested so that Nuffield Trust would be able to carry out appropriate statistical analyses to help explore how well the results of the pre- or post-operative questionnaires correlate with proxy outcomes from HES. Although the PROMs data focus on patients awaiting one of the relevant procedures, Nuffield Trust expected to be able to make inferences about the general applicability of our results to the older population across England, as appropriate.

Analyses of linked HES, ONS and clinical datasets were part of a wider project to evaluate interventions to improve care of frail older people aged over 75 in hospitals. The analyses were focused on developing tools for identifying people who are frail in hospitals, understanding the implications of frailty for individuals and the health service, and quantifying the benefits of better care, namely “comprehensive geriatric assessment” which is an integrated management approach.

Date of death was required because survival is an important outcome for people over 75, it is common (up to half of frail older people die over a two year period), and it is a key indicator of the quality of care. It also has major implications for use of hospitals, which increases at end-of-life and is necessary to estimate the impacts of frailty on hospital use, as well as the potential effects of better care.

The Nuffield Trust converted date of death into an anonymised form of the data, such as week of death, or mortality within specified time-frames from hospital admission to further aggregate the data.

Only substantive employees of the Nuffield Trust will have access to the data and only for the purposes described in this document.

The ONS data was processed in accordance with the standard ONS terms and conditions.

Data was matched to the pseudonymised/non-sensitive HES data held by the Nuffield Trust under a separate Data Sharing Agreement (ref: DARS-NIC-384572-J7P6Y).

NHS Digital provided the requested datasets using Nuffield Trust’s encryption to enable them to link the data with the HES data they already held.

• Surveillance of outcomes and health service use for frail older people. Specific elements of the work would;

1. Develop a series of metrics (indicators), from routinely collected data that reflect the quality of care of older people.

2. Validate those metrics against patient reported health status and clinical databases.

3. Use the validated metrics as surveillance indicators to find regions of high quality care of older people

4. Confirm the surveillance findings by partnering with the relevant authority to understand the local context

5. If evidence of high quality care is established then an in-depth qualitative analysis will be performed to detail the local arrangements and assess the potential for transferability

• Comprehensive Geriatric Assessment (CGA). Specific elements of the work would;

1. Identify the characteristics of recipients of CGA in existing settings

2. Identify the characteristics of those who appear to benefit from CGA

3. Stratify local populations to test who might benefit from CGA more widely

4. Develop interactive tools for providers and commissioners to explore scope for service modifications

5. Assess the relationship between frailty markers (recorded and proxy) and long term care outcomes

Additional processing for CGA analysis:

NHS Digital would receive identifiable person level information from each one of three universities (Newcastle University, Southampton University and Nottingham University) who held detailed clinical datasets relating to frail older people, containing clinical frailty markers and whether the patient received CGA.

The transferred information would consist of only: NHS number, full name, date of birth and address including postcode, in addition to a non identifiable linkage ID. This data was required in order to ensure a robust match at NHS Digital to ensure a high standard in data quality. NHS Digital will receive no other information about any service recipient.

This transfer of information to NHS Digital would occur just once. It was anticipated that there would be 2,000 individuals in total.

This data would be transferred to NHS Digital using NHS Digital’s own secure transfer facilities.

NHS Digital would process the person identifiers. For each service recipient, they would find the relevant pseudonymised identifier, the HESID, in the form held by the Nuffield Trust.

NHS Digital would produce a file for the Nuffield Trust. This file would contain the HESID of each service recipient, alongside other limited pseudonymised information: LSOA of residence, age and gender. It would also include information about the matching technique, and the non identifiable linkage ID.

NHS Digital would finally transfer this file securely to the Nuffield Trust.

The data received from NHS Digital would then be linked, via the non-identifiable linkage ID provided by the sites, to the de-identified clinical datasets held by the Nuffield Trust, and to HES and ONS mortality data via the HESID.

Additional note – third parties:

The Nuffield Trust are not seeking permission for any third parties to access these data, even where these third parties are study partners. The use of this data will be limited to Nuffield Trust for the purposes outlined above only. Data published or provided to third parties will be limited to aggregated data, at area, organisational or cohort-level all with small numbers suppressed in line with HES analysis guide.

The Nuffield Trust would perform its analyses using statistical software including SAS, R and stata.

The Nuffield Trust shall ensure access to data disseminated by NHS Digital is strictly prohibited and must not be accessed by Wavex Technology.

All outputs would be aggregate with small number suppressed in line with the HES Analysis Guide.

Anticipated dates of study reports are listed. All may also include presentational web material (for example slideshows and blog posts), in addition to presentations given in person at relevant research or policy conferences, etc.

• Surveillance of outcomes and health service use for frail older people

The Nuffield Trust anticipated producing a Nuffield Trust final research report to be available in mid to late 2017. At the same time, the Nuffield Trust also aimed to produce papers for peer-reviewed journals such as BMJ Quality and Safety and Age and Ageing, as well as a paper targeted towards a more methodological journal. The Nuffield report would be placed in the public domain, and would contain data at no greater granularity than aggregate with small numbers suppressed.

• Comprehensive Geriatric Assessment (CGA) evaluation

The Nuffield Trust have contributed to a final NIHR report for the HoW CGA study which would be submitted for peer review at the end of January 2018, with publication expected in late 2018. This report would include a tool (excel based, reliant only on aggregated data with small numbers suppressed) for local NHS use - to determine how many people in an area might benefit from CGA.

A paper on the development of a frailty risk score for older people in acute care was submitted to a peer reviewed journal in November 2017 and a decision is pending. Further papers for peer reviewed journals are planned including one focusing on long term outcomes of frailty in the community and one focused on hospital based populations. These are expected to be submitted to peer reviewed journal in Spring 2018. A further report about the relation of frailty measures to admissions will be produced in early 2018. An algorithm to identify frailty risk using HES has also been produced and is subject to intellectual property rights to be shared with a commissioning support unit so that it can be used to support the understanding of the number of frail people in the population and to assess whether it might be possible to implement it at the frontline in hospital systems.

This HESIDs would enable the primary outputs of the research programme to be generated. Specifically Nuffield Trust would be able to determine the extent to which clinical frailty scales predict short, medium and longer term hospital use, survival, the frequency of emergency events and costs related to health activity.

The benefits of the work are seen in terms of decisions made by healthcare commissioners and providers, when thinking about the types of services needed to deliver benefits to patients, as well as by policy makers.

• Surveillance of outcomes and health service use for frail older people

The frail older people work is aiming to develop better indicators to identify good quality provision of care for older people. The work consists of devising and testing new metrics - some of which are drawn from HES data - and then validating these in a number of ways:

- by identifying characteristic areas of good practice;

- by matching outcomes with PROMs;

- by engaging with a number of key experts in the field with whom the Nuffield Trust already have existing links, including via the CGA project that is also mentioned in this application.

In the long term the Nuffield Trust anticipate that the metrics they develop will be used by the care system to monitor and to promote good quality care for older people. Some of this will be integrated with the CGA project and benefit from the methods for dissemination outlined below.

Alongside the reports and peer-reviewed papers, key outputs will be tools that can be applied locally for looking at changes over time which will be supported by web-based materials. These tools will enable decision makers use their own data to monitor key outcome measures over time to identify, for example, whether new care initiatives are improving outcomes or quickly spot sudden deteriorations so that they can be acted upon in a timely fashion. The Nuffield Trust are known experts in this field: for example, the Trust currently have a request from NHS England for work in this area.

• Comprehensive Geriatric Assessment (CGA) evaluation.

The Nuffield Trust’s analyses and project deliverables will contribute to a much more detailed understanding of current models of inpatient care for older people in the UK. The Nuffield Trust will also improve the clarity of definition of the key elements of CGA and its use in hospital settings. Outputs will include a means of evaluating services for frail older people using HES data, a methodology for assessing the relationship between frailty markers and long-terms patient outcomes and costs, an algorithm to identify frail older people using routine hospital data who may subsequently benefit from CGA and a set of tools that will facilitate service redesign and long-term planning for commissioners (see below).

The Nuffield Trust will use a range of new and existing organisations to support the dissemination of finding from the project, for example Clinical Commissioning Groups (CCGs), NIHR Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) (team members are involved with two CLAHRCs currently and have excellent networks with the remaining seven across England), and Academic Health Science Networks (AHSNs). AHSNs will play a pivotal role in promoting the uptake of innovation and best practice and the team will work with the AHSNs to promote adoption and spread of best practice recommendations and the use of resources to support change arising from the findings of the project.

The outputs of the above tool will be combined with a series of health system performance measures that relate specifically to the care of frail older people at area and provider level. These performance metrics, combined with the estimated number of CGA beneficiaries, will allow the Nuffield Trust to estimate the numbers, outcomes, resource use and costs for this group of service users. These estimates will then be used to produce the final “What if” interactive models to be provided to service providers and commissioners, allowing them to explore the scope for modifications to services to (for example) reduce costs or service utilisation, or evaluate the effectiveness of service interventions targeting the frail cohort. Specifically, the final tool would demonstrate the relationship between the scale of patient benefits, resource use and costs based on variable assumptions concerning: numbers receiving CGA, patient type and risk, and relative effectiveness.

In addition, which individual patient characteristics and frailty markers best predict improved outcomes from CGA are currently unknown. It is essential that factors identifying benefit can be derived from routine hospital data to facilitate service level evaluation of health outcomes and health and social care costs. The number of people who might benefit from CGA is estimated to be between 15-50% of older inpatients. Accurate data on the numbers involved in different hospital settings are required to plan and resource appropriate models of service for the projected increasing admissions of older people to hospital. These tools will permit commissioners to plan and resource accordingly.

In addition, by analysing differences between patients recorded as receiving CGA and those who are not, Nuffield Trust will also be able to evaluate the effectiveness of the CGA intervention, in terms of cost and patient outcomes, and also characterise groups of elderly patients who are most likely to benefit from CGA.

The Nuffield Trust have contributed to a final NIHR report for the Hospital Wide (HoW) CGA study which will be submitted for peer review at the end of January, with publication expected in late 2018. This report will include a tool (excel based, reliant only on aggregated data with small numbers suppressed) for local NHS use - to determine how many people in an area might benefit from CGA. A paper on the development of a frailty risk score for older people in acute care was submitted to a peer reviewed journal in November 2017 and a decision is pending. Further papers for peer reviewed journals are planned including one focusing on long term outcomes of frailty in the community and one focused on hospital based populations. These are expected to be submitted to peer reviewed journal in Spring 2018.