Issue 15 / 29 April 2013

LOOKING after older patients should be the core business of the Australian health care system, according to a leading geriatrician.

Professor Balakrishnan Nair, who is also director of the Centre for Medical Professional Development at John Hunter Hospital in Newcastle, said that if Australian medicine was “judged by the way we look after our older patients then we have a long way to go”.

He was commenting on two articles published in JAMA Internal Medicine assessing different models of care for older hospitalised patients in the US.

The first study assessed Acute Care for Elders (ACE) — an interdisciplinary team in a specific geriatric care unit providing hospital care to older patients — and found it reduced costs and rates of 30-day readmissions. (1)

The second study assessed Mobile Acute Care of the Elderly (MACE), a mobile interdisciplinary team of geriatricians, social workers and clinical nurse specialists focused on reducing the risks of hospitalisation, improving care coordination with outpatient practice, discharge planning, and patient and carer education. The researchers found the service was associated with lower rates of adverse events, shorter hospital stays and increased patient satisfaction. (2)

An accompanying editorial in JAMA Internal Medicine said there were several barriers to implementing a coordinated geriatric model of care, such as not enough geriatric specialists to provide care and the challenge of efficient communication. (3)

The financial incentive to create a seamless system of care “does not exist”, the authors wrote.

“However, the most significant barrier to surmount may be the status quo”, they wrote. “Physicians are used to taking responsibility for only a subset of a patient’s health issues and then only in specific settings.”

It was on this point that Professor Nair felt the Australian aged care system was also in trouble.

“We are training more and more specialists and fewer and fewer generalists”, he told MJA InSight.

“We should be treating the patients rather than their organs — the person rather than the disease”, he said. “Patient-centred care, with an interdisciplinary approach, reduces length of stay, morbidity and even mortality in older patients.

“Every hospital in the country should have a geriatric unit with a multidisciplinary approach, but it’s not that way because aged care is not sexy, there’s not enough mileage in it.”

The Australia’s hospitals 2011–12 report shows hospital admissions increased by 17.6% overall (4.1% per year) between 2007–08 and 2011–12, with admissions of people aged 85 years and over up by 40%, an average increase of 9% per year. Patients aged 65 years or more accounted for 39% of admissions in 2011–12. (4)

Professor Gideon Caplan, director of geriatric medicine at the Prince of Wales Hospital in Sydney, told MJA InSight that although he agreed that more geriatric care units were needed, the situation in Australia was much more positive than in the US.

“We have a much higher rate of geriatricians per head of population than they do”, Professor Caplan said.

“In Canada, for example, they have a population of about 30 million. They have nine trainees in gerontology across the whole country. We have about 100, and the number of trainees is increasing, and the number of geriatricians is increasing as well.”

Professor Caplan said the US system had cut training for geriatricians to just one year, undermining the prestige and attractiveness of the speciality.

“Our government recognises that geriatric care is important and they’re funding units across the country”, he said.

“They know that if they can cut the length of stay for older people in hospitals, and decrease the number in aged-care facilities, then that means an ongoing saving for the government. And that’s a necessary direction for the health system.”

1. JAMA Intern Med 2013; Online 22 April
2. JAMA Intern Med 2013; Online 22 April
3. JAMA Intern Med 2013; Online 22 April
4. Australian Institute of Health and Welfare 2013; Australia’s hospitals 201–12


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