title: Bringing geriatricians to the front lines: evaluation of a quality improvement intervention in primary care.
abstract: BACKGROUND
  Frail elders often receive low-quality primary care, yet the optimal role of geriatricians in primary care settings remains uncertain. We evaluated the health utilization impacts of an innovative intervention emphasizing chronic disease self-management and physical activity promotion among frail elders in primary care.
  
  
  METHODS
  The intervention was implemented within two primary care practices at a single clinic serving a large population of frail elders enrolled in a western Washington health plan. Subjects included older patients (age >or=65 years) with disproportionate baseline outpatient service use who attended two on-site visits with a geriatrician during which each received comprehensive assessment and a problem-solving intervention to enhance chronic disease self-management and promote physical activity (N = 146). Our evaluation had a retrospective matched cohort design. Controls receiving primary care at other health plan clinics were matched 3:1 to intervention subjects by sex and a propensity score (N = 437), which was computed using demographic, clinical, and health care utilization factors that were predictive of attending the intervention. Among intervention subjects and controls following the intervention, we compared relative rates of hospitalization, outpatient and specialty visits, nursing home admission, mortality, and prescription of selected high-risk medications, as well as total health care costs.
  
  
  RESULTS
  From March 2002 to November 2003, the geriatrician evaluated 146 of 725 elderly subjects (20%) in the two primary care practices. During a mean follow-up of 1.3 years, intervention subjects had a reduced rate of hospitalization relative to matched controls (incidence rate ratio 0.57; 95% CI: 0.37 to 0.86; P < .01). Intervention and control subjects did not have significantly different rates of specialty visits, outpatient visits, nursing home admission, mortality, or high-risk prescriptions. Relative to matched controls during follow-up, total health care costs were 26.3% lower among intervention subjects (95% CI: 1.3%, 44.9%; P = .04).
  
  
  CONCLUSIONS
  Outpatient geriatric interventions emphasizing collaboration between geriatricians and primary care physicians, chronic disease self-management, and physical activity may reduce hospitalization risk and total health care costs among vulnerable elders.
authors.affiliation: Department of Family and Community Medicine, University of California, Davis, Sacramento, CA 95817, USA. Joshua.fenton@ucdmc.ucdavis.edu
authors.forename: Joshua J
authors.initials: JJ
authors.lastname: Fenton
authors.forename: Martin D
authors.initials: MD
authors.lastname: Levine
authors.forename: Lisa D
authors.initials: LD
authors.lastname: Mahoney
authors.forename: Patrick J
authors.initials: PJ
authors.lastname: Heagerty
authors.forename: Edward H
authors.initials: EH
authors.lastname: Wagner
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002908:Chronic Disease; D003363:Cost Control; D019468:Disease Management; D011307:Drug Prescriptions / Q000706:statistics & numerical data; D005260:Female; D016330:Frail Elderly; D005853:Geriatrics / Q000191:economics / Q000592:standards*; D017048:Health Care Costs; D006293:Health Promotion; D006299:Health Services for the Aged / Q000191:economics / Q000592:standards* / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008511:Medicine / Q000706:statistics & numerical data; D009043:Motor Activity; D009735:Nursing Homes / Q000592:standards; D011320:Primary Health Care / Q000191:economics / Q000592:standards* / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000592:standards*; D012189:Retrospective Studies; D020377:Self Efficacy; D013038:Specialization; D014481:United States / Q000453:epidemiology