Looking inside the black box of comprehensive geriatric assessment: a classification system for problems, recommendations, and implementation strategies.

OBJECTIVE: To develop and test the inter-rater reliability of a coding system for geriatric problems identified through Comprehensive Geriatric Assessment (CGA) of hospitalized older persons, recommendations generated by the assessment, and implementation strategies for these recommendations. DESIGN: Validation study. SETTING: A health maintenance organization and a geriatrics academic program. PARTICIPANTS: A total of 49 hospitalized older persons, who met at least 1 of 13 inclusionary "targeting" criteria, two geriatricians, and one social worker who coded forms. MEASUREMENTS: Standardized coding of CGA consultation sheets into (1) geriatric problems identified, (2) recommendations, and (3) implementation strategies; inter-rater reliability testing of coding system using two physicians and a social worker. RESULTS: On average, each assessed patient had 4.8 recommendations. The largest percentages of recommendations were for non-physician referrals (18.2%), advance directives (13.4%), medication adjustments (11.5%), diagnostic evaluation/monitoring (11.5%), and community services (10.9%). The proportions of agreement between raters in coding problems ranged from 0.77 to 0.90, in coding recommendations from 0.69 to 0.86, and in coding implementation strategies from 0.68 to 0.83. CONCLUSION: A classification system for measuring some components of the process of care of CGA has satisfactory inter-rater reliability, can be adapted for other settings, and may provide valuable insight into determining which components of CGA confer health benefits.

Surrogate decision-makers' satisfaction with the placement of feeding tubes in elderly patients.

OBJECTIVE: To assess the satisfaction of surrogate decision-makers with the decision to place feeding tubes in elderly patients with impaired decision-making capacity. DESIGN: Inception cohort followed for 5 weeks. SETTING: Four hospitals in the greater Los Angeles area. PARTICIPANTS: Fifty-eight surrogate decision-makers for elderly patients (over 60) who recently received a first-time percutaneous endoscopic gastrostomy. Participants were identified through the endoscopy departments at the four hospitals. MEASUREMENTS: We surveyed surrogates by telephone within 5 days of placement for background data and after 5 weeks of use to assess satisfaction with the decision. The main outcome variables at follow-up were: surrogate satisfaction; whether the surrogate would repeat the decision; whether the surrogate had considered removal of the tube; and surrogates' perception of patients preference for the tube. RESULTS: After 5 weeks of use, 84% of surrogates stated that they would repeat the decision. Fifty-nine percent of surrogates described themselves as satisfied with the decision, and 17% were dissatisfied. Only 10% had considered removing the tube. After 5 weeks of use, 36% of surrogates felt that the patient would prefer the tube, and 31% felt they would not. CONCLUSIONS: Most surrogates we studied would repeat the decision to have a feeding tube after experiencing its effects for 5 weeks. However, almost one-third felt the patient would not want the tube. Physicians and surrogates may need to place greater emphasis on patients' wishes before placing feeding tubes and when reassessing their benefit to the patient after being placed.