Camilla L. Wong

Background: Comprehensive Geriatric assessment (CGA) improves the well‐being of older adults, but evidence suggests not all recommendations are implemented by clinicians and patients. Currently, there is no review of interventions to improve clinician implementation and older adults' adherence to CGA recommendations. Therefore, the aim of this scoping review is to identify interventions that have been evaluated to improve clinicians' implementation of and patients' adherence to CGA recommendations. Methods: We used Arksey and O'Malley's scoping review framework with the advancements made by Levac et al. We searched OVID MEDLINE, OVID EMBASE, EBSCO CINAHL, APA PsycINFO, and Cochrane Central from inception until November 14, 2024. Two independent reviewers were used for study selection using Covidence. We screened 11,404 titles and abstracts, 111 full texts, and included 16 total manuscripts (describing 6 intervention studies) in the review. Results: Among the interventions intended to improve clinician implementation, such as strong recommendations by the geriatrician to primary care and patients, physician implementation of CGA recommendations ranged from 59% to 73.9% and patient adherence to recommendations ranged from 59% to 76%. Recommendations easier to implement, such as medication changes, were more adhered to than recommendations for lifestyle changes. Clinician implementation is likely influenced by concordance with patients, involvement during and/or degree of communication after the CGA. The studies suggest that patient adherence depends on perceived relevance of recommendations and patient‐provider relationships. Conclusion: There is a knowledge gap regarding the uptake of CGA recommendations in the context of contemporary healthcare systems. No interventions examined the value of digital technologies in improving implementation/adherence. Future efforts to increase clinician implementation of CGA recommendations and patient adherence to CGA recommendations should be considered in tandem.

Introduction: The number of older adults living with frailty undergoing gastrointestinal cancer surgery is increasing. To address the unique needs of the population, a whole pathway perioperative geriatrics strategy—PRIME—was developed to integrate geriatric principles into surgical care. The objective of this study was to evaluate the implementation of PRIME using validated structural, process, and outcome quality indicators. Materials and Methods: This retrospective cohort study included 106 consecutive patients aged 70 years and older who underwent gastrointestinal surgery for cancer or pre-cancerous lesions at a single institution between 1 July 2020 and 5 October 2023. The whole pathway perioperative geriatrics strategy, PRIME, includes preoperative comprehensive geriatric assessment (CGA), collaborative care between surgery, geriatrics, and anesthesia, and post-operative co-management. Implementation was evaluated using validated structural, process, and outcome quality indicators. Results: Most structural indicators (five of eight) were implemented. In terms of process indicators, 96.2% (n = 102) received CGA prior to or within 24 h of admission. Adherence to screening was high: 97.2% for dementia, 96.2% for functional status, and 95.3% for frailty. The median number interventions resulting from CGA was 17 (IQR 14–20). Serious complication, delirium, and functional decline occurred in 19.8%, 27.1%, and 19.8%, respectively. Conclusions: Implementation of a perioperative geriatrics strategy for older adults undergoing gastrointestinal cancer/pre-cancer lesion surgery is feasible, with high adherence to structural and process quality indicators.

Purpose There is variable and suboptimal use of fascia iliaca compartment nerve blocks (FICBs) in hip fracture care. Our objective was to use an evidence-based and theory-informed implementation science approach to analyze barriers and facilitators to timely administration of FICB and select evidence-based interventions to enhance uptake. Methods We conducted a qualitative study at a single centre using semistructured interviews and site observations. We interviewed 35 stakeholders including health care providers, managers, patients, and caregivers. We mapped barriers and facilitators to the Theoretical Domains Framework (TDF) and Consolidated Framework for Implementation Research (CFIR). We compared the rate and timeliness of FICB administration before and after evidence-based implementation strategies were applied. Results The study identified 18 barriers and 11 facilitators within seven themes of influences of FICB use: interpersonal relationships between health care professionals; clinician knowledge and skills related to FICB; roles, responsibilities, and processes for delivering FICB; perceptions on using FICB for pain; patient and caregiver perceptions on using FICB for pain; communication of hip fracture care between departments; and resources for delivering FICBs. We mapped the behaviour change domains to eight implementation strategies: restructure the environment, create and distribute educational materials, prepare patients to be active participants, perform audits and give feedback, use local opinion leaders, use champions, train staff on FICB procedures, and mandate change. We observed an increase in the rates of FICBs administered (48% vs 65%) and a decrease in the median time to administration (1.63 vs 0.81 days). Conclusion Our study explains why FICBs are underused and shows that the TDF and CFIR provide a framework to identify barriers and facilitators to FICB implementation. The mapped implementation strategies can guide institutions to improve use of FICB in hip fracture care.

Background Best practice recommendations support the implementation of perioperative geriatric care models that tailor to the specific needs of older adults undergoing surgery. The objective of this study was to describe the current proactive perioperative geriatric programs and pathways in Canadian hospitals. Methods A survey of geriatricians, surgeons, and anesthesiologists practicing in Canada combined with phone interviews of a subset of participants were used to determine characteristics of perioperative geriatric pathways or programs including eligibility, team composition, and intervention elements. Results Analysis of 132 survey respondents and 24 interviews showed 47% (40 out of 85) of hospitals described had elements of a perioperative geriatrics program and 20% had two or more elements. Eleven themes emerged including: how periopera-tive geriatric care programs built geriatric competencies in other health-care providers; geriatric assessment identified risks not captured in standard perioperative risk assessment; perceived value for patients and the health-care team; delirium prevention was addressed; most programs were reactive; most programs were informal; virtual care may be used to meet demand; successful implementation required system buy-in with collaboration across subspecialties; mechanisms to drive improvement were accountability and data evaluation; few clinicians with geriatric expertise; and other priorities limited program implementation. Conclusions There were few hospitals in Canada with perioperative geriatric care models and even fewer with elements spanning the entire perioperative pathway. Strengths, weaknesses, opportunities, and threats to inform the implementation and sustainability of perioperative geriatric care in the Canadian context were identified in this national environmental scan.

During the COVID-19 pandemic, physicians provided virtual care to minimize viral transmission. This concurrent triangulation mixed-methods study assesses the use of synchronous telephone and video visits with patients and asynchronous eConsults by geriatric providers, and explores their perspectives on telemedicine use during the pandemic. Participants included physicians practicing in Ontario, Canada who were certified in Geriatric Medicine, or Care of the Elderly, or who were the most responsible physician in a long-term care for at least 10 patients. Participants’ perspectives were solicited using an online survey and themes were generated through a reflexive thematic analysis of survey responses. We assessed the current use of each telemedicine tool and compared the proportion of participants using telemedicine before the pandemic with self-predicted use after the pandemic. We received 29 surveys from eligible respondents (87.9% completion rate), with 75.9% being geriatricians. The telephone was most used (96.6%), followed by video (86.2%) and eConsults (64%). Most participants using telephone and video visits had newly implemented them during the pandemic and intend to continue using these tools post-pandemic. Our thematic analysis revealed that telemedicine plays an important role in the continuity of care during the pandemic, with increased self-reported positive perspectives and openness towards use of virtual care tools, although limited by inadequate physical exams or cognitive testing. Its ongoing use depends on the availability of continued remuneration.