Objectives To estimate the cost-effectiveness of a pragmatic trial of comprehensive geriatric assessment adapted to primary care, compared with care as usual. Design Within-trial cost-effectiveness study of a prospective controlled multicenter trial. Setting and Participants Nineteen primary care practices in Sweden. The original trial included 1304 individuals aged ≥75 years at high risk of hospitalization selected using a prediction model. From the original trial, 369 individuals participated in the cost-effectiveness analysis, 185 in the intervention group and 184 in the control group. Mean age was 83.9 years and 57% of the participants were men. Methods We obtained health care costs from administrative registries. Community costs and health-related quality of life data were obtained from a questionnaire sent to participants. Health-related quality of life was measured using EQ-5D-3L and quality-adjusted life years were calculated. We analyzed all outcomes according to intention to treat, and adjusted them to age, gender, and risk score (risk of hospitalization in the next 12 months). The primary outcome was the incremental cost-effectiveness ratio associated with the intervention at follow-up after 24 months. Results The difference in total cost (incremental cost) between intervention and control groups was USD −11,275 (95% CI −407 to −22,142). The incremental effect in quality-adjusted life years was −0.05 (95% CI −0.17 to 0.08). In the cost-effectiveness plane that illustrates the uncertainty of the analysis, 77.9 of the observations were within the south-east quadrant, implying lower cost and greater effect in the intervention group. Conclusions and Implications The results suggests that a primary care comprehensive geriatric assessment intervention delivered to older adults at high risk of hospitalization is cost-effective at follow-up after 24 months. The use of a prediction model to select participants and an intervention with a low cost is promising but requires further study.

Objective: To explore frail older persons’ perceptions of the future and the end of life.

Design: Qualitative content analysis of individual semi-structured interviews.

Setting: Nine primary health care centres in both small and middle-sized municipalities in Sweden that participated in the intervention project Proactive healthcare for frail elderly persons.

Subjects/Patients: The study includes 20 older persons (eight women and 12 men, aged 76–93 years).

Main outcome measures: Frail older persons’ perceptions of the future and end of life.

Results: The analysis uncovered two main categories: Dealing with the future and Approaching the end of life. Dealing with the future includes two subcategories: Plans and reflections and Distrust and delay. Approaching the end of life includes three subcategories: Practical issues, Worries and realism, and Keeping it away.

Conclusion: This study highlights the diverse ways older people perceive future and the end of life. The results make it possible to further understand the complex phenomenon of frail older persons’ perceptions on the future and the end of life.

Demographic change is leading to a higher proportion of older adults in most parts of the world. A minority of older adults have poor health, but this group has high care needs due to frailty and/or multimorbidity. Guidelines for the management of frailty emphasise early detection of frailty and recommend comprehensive care approaches in primary care, but the evidence for these interventions is low. To provide effective and individualised care, the health system needs to identify these patients and develop proactive interventions to improve quality of life and avoid treatments that are of no benefit to the individual.  

The aim of this thesis was to study the effects of a proactive primary care working model in which vulnerable older adults were identified and received individually tailored care, using an adaptation of comprehensive geriatric assessment (CGA). 

Methods: A pragmatic controlled trial was conducted in 19 primary care practices in Sweden from 2017 to 2020. A predictive model, using electronic medical records to assess the risk of hospital admission, selected participants at high risk. Participants in the intervention practices were offered a comprehensive geriatric assessment in their primary care practice and subsequent follow-up by a team consisting of a nurse and the patient's doctor. A new CGA tool - PASTEL (Primary care ASsessment Tool for Elders) was used for assessment and care planning. The primary outcome for the intervention was hospital care days and secondary outcomes were hospital care episodes, mortality, outpatient visits, healthcare costs and cost-effectiveness. The outcomes were adjusted for age, sex and risk score and ana-lysed according to intention-to-treat. 

The predictive model was validated, and performance was assessed using the C-statistic. Focus group interviews were conducted to explore primary care nurses' and doctors' experiences with the new tool PASTEL. 

Results: 1304 older adults were included in the trial. The mean age was 82.2 years, 51% were female. During the follow-up period of 24 months, the relative risk reduction of hospital care days in the intervention group was - 22% (CI 95% = -35% to - 4%, p = 0.02) compared with usual care. There was no significant difference in mortality and outpatient visits. The reduction in healthcare costs was - € 4324 (- € 7962 to - € 686, p = 0.02). The intervention was cost-effective compared with usual care, mainly due to lower costs.

The predictive model had an AUC of 0.69 (CI 0.68- 0.70). Primary care staff considered PASTEL valuable and feasible in the primary care context.

In conclusion, the results of this thesis indicate that vulnerable older adults at risk of hospitalisation can be identified by a predictive model. Proactive intervention with a comprehensive geriatric assessment adapted to pri-mary care can reduce the need for hospital care. Future studies in similar contexts are needed to determine whether these results are generalisable.

Background The healthcare for older adults is insufficient in many countries, not designed to meet their needs and is often described as disorganized and reactive. Prediction of older persons at risk of admission to hospital may be one important way for the future healthcare system to act proactively when meeting increasing needs for care. Therefore, we wanted to develop and test a clinically useful model for predicting hospital admissions of older persons based on routine healthcare data. Methods We used the healthcare data on 40,728 persons, 75-109 years of age to predict hospital in-ward care in a prospective cohort. Multivariable logistic regression was used to identify significant factors predictive of unplanned hospital admission. Model fitting was accomplished using forward selection. The accuracy of the prediction model was expressed as area under the receiver operating characteristic (ROC) curve, AUC. Results The prediction model consisting of 38 variables exhibited a good discriminative accuracy for unplanned hospital admissions over the following 12 months (AUC 0.69 [95% confidence interval, CI 0.68-0.70]) and was validated on external datasets. Clinically relevant proportions of predicted cases of 40 or 45% resulted in sensitivities of 62 and 66%, respectively. The corresponding positive predicted values (PPV) was 31 and 29%, respectively. Conclusion A prediction model based on routine administrative healthcare data from older persons can be used to find patients at risk of admission to hospital. Identifying the risk population can enable proactive intervention for older patients with as-yet unknown needs for healthcare.

Objective: Comprehensive geriatric assessment (CGA) is recommended for the management of frailty. Little is known about professionals experiences of CGA; therefore we wanted to investigate the experiences of staff in primary care using a new CGA tool: the Primary care Assessment Tool for Elderly (PASTEL). Design: Focus group interviews. Manifest qualitative content analysis. Setting: Nine primary health care centres in Sweden that participated in a CGA intervention. These centres represent urban as well as rural areas. Subjects: Nine nurses, five GPs and one pharmacist were divided into three focus groups. Main outcome measures: Participants experiences of conducting CGA with PASTEL. Results: The analysis resulted in four main categories. A valuable tool for selected patients: The participants considered the assessment tool to be feasible and valuable. They stated that having enough time for the assessment interview was essential but views about the ideal patient for assessment were divided. Creating conditions for dialogue: The process of adapting the assessment to the individual and create conditions for dialogue was recognised as important. Managing in-depth conversations: In-depth conversations turned out to be an important component of the assessment. Patients were eager to share their stories, but talking about the future or the end of life was demanding. The winding road of actions and teamwork: PASTEL was regarded as a good preparation tool for care planning and a means of support for identifying appropriate actions to manage frailty but there were challenges to implement these actions and to obtain good teamwork. Conclusion: The participants reported that PASTEL, a tool for CGA, gave a holistic picture of the older person and was helpful in care planning.