See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/9018452

The effectiveness and costs of comprehensive

geriatric evaluation and management

Article in Critical Reviews in Oncology/Hematology December 2003

DOI: 10.1016/j.critrevonc.2003.06.005 Source: PubMed

CITATIONS READS

50 114

1 author:

G. Darryl Wieland
Duke University
151 PUBLICATIONS 4,818 CITATIONS

SEE PROFILE

All in-text references underlined in blue are linked to publications on ResearchGate, Available from: G. Darryl Wieland
letting you access and read them immediately. Retrieved on: 11 September 2016
 Critical Reviews in Oncology/Hematology 48 (2003) 227237

The effectiveness and costs of comprehensive geriatric

evaluation and management
Darryl Wieland a,b,
a Division of Geriatric Medicine, University of South Carolina School of Medicine, 9 Medical Park, #630, Columbia, SC 29204, USA
b Division of Geriatrics Services, Palmetto Health Richland, Columbia, SC, USA

Accepted 30 June 2003

Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
2. Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
3. Are geriatrics interventions effective?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
4. Do geriatrics interventions contain costs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Biography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

Abstract

Comprehensive geriatric assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining a frail elderly
persons medical, psychological, and functional capabilities in order to develop a coordinated and integrated plan for treatment and long-term
follow-up. Geriatrics interventions building on CGA are defined from their historical emergence to the present day in a discussion of their
complexity, goals and normative components. Through literature review, questions of the effectiveness and costs of these interventions are
addressed. Evidence of effectiveness is derived from individual trials and, particularly, recent systematic reviews. While the trial evidence
lends support to the proposition that geriatric interventions can be effective, the results have not been uniform. Review of meta-regression
studies suggests that much of this outcome variability is related to identifiable program design parameters. In particular, targeting the frail,
an interdisciplinary team structure with clinical control of care, and long-term follow-up, tend to be associated with effective programs.
Answers to cost-effectiveness questions also vary and are more rare. With some exceptions, existing evidence as exists suggest that geriatrics
interventions can be effective without raising total costs of care. Despite the attention given to these questions in recent years, there is still
much room for clinical and scientific advance as we move to better understand what CGA interventions do well and in whom.
2003 Elsevier Ireland Ltd. All rights reserved.

Keywords: Geriatric intervention; Effectiveness; Cost-effectiveness; Controlled clinical trial; Randomized clinical trial; Comprehensive geriatric assessment;
Geriatric evaluation and management; Health care utilization; Meta-analysis

1. Introduction

Comprehensive geriatric assessment (CGA) is a multidi-

mensional interdisciplinary diagnostic process focused on
Corresponding author. Tel.: +1-803-434-4330; determining a frail elderly persons medical, psychological,
fax: +1-803-434-4331. and functional capabilities in order to develop a coordinated
E-mail address: darryl.wieland@palmettohealth.org (D. Wieland). and integrated plan for treatment and long-term follow-up

1040-8428/$ see front matter 2003 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.critrevonc.2003.06.005
228 D. Wieland / Critical Reviews in Oncology/Hematology 48 (2003) 227237
[1]. From its inception, CGA has been the foundation for
a proliferating array of intervention packages intended for
the frail elderly population as it is encountered in different
parts of the health care system. The objective of this paper is
to provide a critical overview of the published experimental
research on the effectiveness of CGA interventions.
In August 2002, numerous literature and research
databases were probed using the search terms comprehensive
geriatric assessment, geriatric evaluation and management
(GEM), and aged in combination with interdisciplinary
team and MESH terms for various care environments (e.g.
ambulatory care). These were combined with randomized
control and controlled clinical trials, health outcomes, ef-
fectiveness, health care utilization, quality of life, health
care satisfaction, health care costs, and cost-effectiveness.
Searches included indexed publications from 1990 forward.
Selected for consideration were reports of studies (1) in
which CGA in some form is the core problem-defining and
care-planning process; (2) in which elderly patients (age
65) comprise the study subjects; (3) in which experimen-
tal or quasi-experimental designs are employed; and (4) in
which health outcomes, procedural endpoints, or costs are
reported. Literature reviews were also recovered using the
same terms and selection criteria.
The size and diversity of the geriatrics literature has grown
greatly in the past 20 years. Thus, any reasonably brief
and comprehensible review cannot describe and analyze all
individual trials within all types of CGA-programs.1 In-
stead, in discussion of the range of clinical outcomes, I
limit myself to discussion of key recent trials representative
of the CGA-program types. More attention is given to the
meta-analytic reviews that address parts of this literature,
and patterns of findings therein. (Individual trials reporting
on cost impacts are described in more detail below.)
2. Background
Geriatrics emergence paralleled that of modern medicine
in the developed countries from the beginning of the last
century. At its beginnings in the United Kingdom, it was
said that geriatrics exists because of the hardness of mens
hearts. Despite subsequent advances in health care gener-
ally and in geriatric services, the dictum reflected the expec-
tation in society and in much of the health profession that
medical care may be ineffective or futile for many elderly
patients. The twin burden on geriatricsthe health care pro-
fessions and services addressing these patientshas been to
demonstrate that it contains the costs of caring for these el-
derly patients while producing valued outcomes for patients
and their families.
Under this mandate, the field began early to work against
clinical nihilism by showing geriatrics can be effective if
1 A complete as searched reference list of CGA-based intervention
trials reporting health outcomes is available from the author.
care outcomes are both appropriately defined (independence
in instrumental and basic activities of daily living versus re-
turn to work; quality versus length of life) and socially val-
ued [2]. As it evolved, part of this strategy has been to lay
claim not only to palliation for highly debilitated institution-
alized older people, but to rehabilitation and increasingly to
integrated care (preventive, restorative and primary care) for
frail elderly living in communities and those at risk for
functional decline as well as for misadventures in the usual
care system.
Once leaving the workhouse infirmary in the UK, geri-
atrics interventions have taken root where stakeholders have
envisioned opportunities for cost containment and outcome
improvement. Form has followed financing, and models have
rooted where usual care is thought to be particularly ineffi-
cient for geriatric patients. In the US, this has been exem-
plified by the proliferation of GEM units in the 1980s in
veterans hospitals [3], and the rise in the 1990s of integrated
service and financing models such as the chronic care model
(CCM) [4] and the programs of all-inclusive care for the
elderly (PACE) in the 1990s [5].
Geriatric patients have come to be defined not by their
age but by their frailty, the complexity of their clinical status
and needs, the uncertainty of their course and responsive-
ness, and the fragility/resilience of their familial, caregiving
resources. Mirroring the complexity of patients problems
and circumstances, geriatrics interventions are complex and
many pronged, and their treatment goals and strategies shift-
ing according to changes in patient status and circumstances.
It is important to understand this point at the beginning,
because our knowledge base concerning the clinical- and
cost-effectiveness of CGA-based interventions has surely
been affected by this inherent complexity. Thus, while there
is a common understanding that CGA is appropriate for as-
sessment of frail elderly patients, geriatric assessment and
management programs vary in terms of structural compo-
nents and care processes not only across Table 1s types
but within. Any cursory review of the trial literature will
show thatnot only have trial results been inconsistently
replicatedno trial has reproduced the experimental as-
sessment and interventions (or usual care conditions) of
any other. Even multicenter trials, in which attempts at stan-
dardization of admission criteria and assessment process
have been made, have encountered considerable organi-
zational variability associated with outcome heterogeneity
[6,7].
If one realizes that CGA-based intervention programs are
inherently complex, and not merely insufficiently standard-
ized, it is possible to glean some lessons from the trial liter-
ature, despite the limited external validity of the individual
studies. Recent methodological work addressing complex
intervention trials suggests that identification of minimum
specifications, i.e. salient elements of patient selection,
structure and process, provides a means of classifying, ana-
lyzing and disseminating these interventions [8]. Turning to
the CGA literature, it is possible to identify at least a few of
 D. Wieland / Critical Reviews in Oncology/Hematology 48 (2003) 227237
Table 1
A spectrum of geriatric intervention programsa
Hospital-based
Acute care for the elderly (ACE) units and related acute services [9]b,c
Geriatric evaluation and management (GEM) units [10,11]c
Geriatric consultation services [12]
Syndrome-specific units/teams [13]c
Community
Hospital discharge support services [14,15]b,d,e
Hospital-at-home [16]f
Day hospital [17]b,c
Geriatric home care [18]
Outpatient GEM clinics [19,20]
Preventive home visit programs [21]g
Nursing home
Subacute units [22]
Primary-care teams
Integrated service/financing models
Chronic care management (CCM) model [23]
Program of all-inclusive care for the elderly [5,24]
a Citations are to key controlled clinical or randomized controlled
trials that include both health and cost impact endpoints.
b Forster et al. [25].
c Parker et al. [26].
d Parkes and Shepperd [27].
e Hyde et al. [29].
f Shepperd and Iliffe [28].
g Stuck et al. [30].
such key minimum specifications. They include: (1) target-
ing older patients for geriatric assessment and management
based on their ability to benefit from that management in
terms of appropriate outcomes, e.g. addressing the frail and
pre-frail in geriatric primary care toward preservation of
independent living and community tenure versus address-
ing the frail and already disabled in community-based or
institutional integrated care toward maintaining function,
dignity and autonomy; (2) multidimensional or comprehen-
sive geriatric assessment employing a variety of screen-
ing and assessment tools, with a focus on function; (3)
patient-centered, problem-driven, goal-oriented manage-
ment, provided with capacity to control the intervention
elements and provide follow-up or chronic care over the
long term; and (4) assessment and management conducted
by an interdisciplinary team comprised (minimally) of a
geriatric physician, a nurse, and social worker, but often a
larger team depending on service setting and goals.
3. Are geriatrics interventions effective?
There is a fairly long line of geriatrics outcome (effec-
tiveness) trials, as well as analytic or systematic reviews.
We briefly present review results concerning effectiveness.
While literature documents geriatrics service effectiveness
in a variety of delivery forms for a range of outcomes,
including improved or better maintained functional status,
survival, increased community tenure, and other outcomes,
229
results are not uniform. Systematic reviewers have used
meta-analytic techniques in attempts to clarify the record
on effectiveness, and to explore organizational features that
may be associated with more effective service models (e.g.
[3032]). However, the same complexity inherent in geri-
atrics interventions that makes single site intervention trials
irreplicable and multicenter studies problematic, also create
problems for interpreting such reviews [26,33].
In the early 1990s, Stuck et al. became the first group to
apply systematic review methods to CGA trials [31]. First,
the then-available 28 trials were groups into institutional
and non-institutional intervention programs. Among insti-
tutional programs, hospital GEMs and inpatient geriatric
consultation teams were identified as discrete types. The
former were all geographic units in control of the treat-
ments of their patients, at least during their stays. The latter
were non-geographic, most did not have control like the
GEMsinstead, most of these services simply produced
lists of treatment recommendations for the primary-care
physicians and did not follow patients past discharge.
Among non-institutional programs, distinctions were drawn
among home discharge support services that facilitated
home placement of elderly patients from acute hospitals,
outpatient GEM clinics, and preventive home visit services.
The outpatient GEM trials are a particularly mixed group of
interventions, some narrowly targeting frail elderly patients
post hospital discharge, others admitting most patients di-
rectly from the community; some having a more extensive
CGA and interdisciplinary teams, others performing more
minimal multidimensional assessments and involving fewer
providers; some generating treatment plans and referring
patients back to regular sources of ambulatory care, others
implementing care plans for a short term, and still others
assuming the role of primary-care provider. In contrast, pre-
ventive home visit services provide widespread, relatively
low intensity multidimensional screening of community el-
derly in order to uncover those at risk for functional decline
or institutionalization for more focused management (the
means for which are variable) and repeated follow-up (also
variable).
Among the main effects of geriatric intervention in the
meta-analysis were significant reductions of mortality for
GEM versus usual care at 6 months, and for preventive home
visit programs at 3 years. The likelihood of living in the
community at end of follow-up was significantly greater for
GEMs, home discharge support and visit services. GEM care
was also associated with significant improvement in physi-
cal function at 1 year. While these results were interpreted
as strongly supporting the effectives of CGA, some caution
to the reader is in order. First, the review is out of date. Fur-
ther, because of the limited number of available trials, the
complexity of the interventions, and diversity of interven-
tions between and within type, the specific applicability of
results is limited. That is, it is difficult to conclude from the
single trial what aspects of the experimental or usual care
may have been responsible for the results.
230 D. Wieland / Critical Reviews in Oncology/Hematology 48 (2003) 227237

Table 2
Features of geriatric intervention programs found to be associated with improved outcomes
Intervention feature Endpoint (timing) Intervention type/class Source

Clinical control Mortality reduction (1 year) All hospital-based services (GEM, consultation, Wieland and
ACE, discharge support svcs) Rubenstein [32]
Mortality reduction (2 years) Preventive home visit services Stuck et al. [31]
Improved community tenure (6 months) All hospital services (GEM + consult teams) Stuck et al. [31]
Improved community tenure (1 year) Hospital geriatric consultation services; all hospital Stuck et al. [31]
services
Improved community tenure (2 years) Preventive home visit services Stuck et al. [31]
Long-term follow-up Mortality reduction (1 year) Inpatient GEMs Stuck et al. [31]
Improved functional status (1 year) Hospital geriatric consultation services Stuck et al. [31]
Higher number of follow-up Risk of nursing home (NH) admission Preventive home visit services Stuck et al. [30]
visits (study end)
Partial targeting (exclusion Improved community tenure (6 months) All hospital services Stuck et al. [31]
of too healthy)
Combinations
Clinical control and full Mortality reduction (1 year) All hospital-based services (GEM, consultation, Wieland and
targeting (exclude too ACE, discharge support svcs) Rubenstein [32]
well/disabled-ill)
Multidisciplinary Improved functional status (study end) Preventive home visit services Stuck et al. [30]
assessment and high
follow-up
Interdisciplinary team Shorter length-of-stay (index discharge); VA inpatient GEMs (vs. VA GEMs lacking teams) Wieland et al. [35]a
structure decreased NH placement; increased
home discharge rate
GEM structure and Shorter LOS; decreased NH placement; Compliant vs. non-compliant VA GEMs Wieland et al. [35]a
process standardsb increased home discharge rate
a Non-experimental system surveys.
b Five standards included: (1) performing comprehensive assessment; (2) having an interdisciplinary team meeting weekly of more; (3) targeting
admissions; (4) having a geographic unit on an acute or intermediate care service; and (5) providing either inpatient treatment and rehabilitation or
outpatient follow-up care.

Given the program diversity, it was more enlightening to
look beyond these main effects to explore (1) what variable
program features (intervention covariates) reduced effect
heterogeneity in meta-regression analysis where outcomes
were not by decision rule statistically poolable (endpoint het-
erogeneity), and (2) were at the same time associated with
improved outcome (program effectiveness) (Table 2).2 In
the same paper [31], we reported that improved patient sur-
vival at 1 year versus usual care was associated specifically
with GEMs providing long-term (post-discharge) follow-up.
Improved survival was also detected for those preventive
home visit services (at 2 yearsversus usual care) with
clinical controlin this context, meaning the service was
an extension of patients source of primary care, and pro-
vided care rather than simply giving consultative advice.
The same effect was found for all non-institutional geriatrics
programs with clinical control. Likelihood of patients liv-
2 Here, too, however, special caveats are needed. The lack of de-
tailed description in the primary trials of experimental and control struc-
ture/process means that characterizing whether an intervention has or
lacks some salient quality is highly subjective. Meta-regression in this
application is at best regarded useful for hypothesis generation and ex-
ploratory analysis in the manner of any secondary subgroup analysis of
prospective trial data [27,30].
ing in the community was found significantly improved at
1 year versus usual care for those geriatric consultation ser-
vices with clinical control (in this context, clinical control
meaning that the consultation teams had responsibility for
implementing at least part of their care plan for the duration
of patients hospital stay). In the institutional service tri-
als group, clinical control also was associated with patients
spending more of the first follow-up year in the community;
increased 2-year community tenure was also observed in the
trials of preventive home visit services. Inpatient consulta-
tion services providing longitudinal follow-up were effec-
tive versus usual care in terms of improved 1-year functional
status. Finally, all institutional services (GEMs and consul-
tation teams) characterized by clinical control and targeting
(exclusion of patient too health or too ill/disabled to benefit)
improved functional status at follow-up versus usual care.
A few years later, a limited update focusing on endpoint
mortality in the hospital-based geriatrics service interven-
tion trials was performed, adding five new trials from the
mid-1990s [32]. This review, too, now needs updating, but
as an example of exploratory analysis of effective pro-
gram features it is still pertinent. Here again meta-regression
was employed to explore endpoint heterogeneity. Very sim-
ply, a geriatrics intervention was considered targeted if
it excluded both patients too well (i.e. the non-frail) and
 D. Wieland / Critical Reviews in Oncology/Hematology 48 (2003) 227237
too ill (either terminally ill or too disabled to return to
the community) to benefit. Targeting was a variable charac-
teristic for GEMs, consultation teams, and home discharge
support services. The one trial of an acute care for the el-
derly (ACE) unit [34] was untargeted, insofar as ACEs (un-
like GEMs) are admitting services for which most acutely
ill elderly patients are eligible. Control over delivery of
at least some of the geriatrics treatments (versus treat-
ment recommendations only to primary physicians/unit
staff) also cut across intervention types studied. Control
was characteristic of all inpatient GEMs, discharge support
teams, one consultation service, and the ACE trial. A few
hospital-based geriatrics interventions featured both these
characteristicsbut no one type resided entirely within this
box.
Results for all 22 trials and for the subgroup of eleven
targeted trials were not poolable, and the combined effect
estimates lay near unity [32]. The probability that the 14
trials in which the geriatric intervention exercised clinical
control were combinable was still low (homogeneity P =
0.16), but the combined mortality-effect estimate of those
interventions versus usual care increased (OR = 0.81; 95%
CI: 0.670.97). Furthermore, the subset of eight trials in
which interventions both had clinical control and targeted
admissions were less diverse (homogeneity P = 0.36), and
a synergy is suggested by its mortality reduction effect esti-
mate (OR = 0.70; 95% CI: 0.52, 0.93).
Evidence for the relationship between variable geriatrics
program components and program effectiveness may be
sought not only from clinical trials but also from provider
surveys. In 1991, VA inpatient GEM units were surveyed, in
order to determine the extent of their adherence to generally
advocated structure and process standards, and to examine
the relationship between adherence and length-of-stay and
community-discharge endpoints [35]. The five standards
qualifying a GEM as adherent were: (a) routine performance
of comprehensive assessment; (b) having a core team of
physician, nurse, and social worker meeting at least weekly;
(c) evidence of having control over admissions or targeting;
(d) being situated on acute or intermediate medicine versus
nursing or psychiatry units; and (e) providing either inpatient
treatment and rehabilitation, post-discharge treatment and
follow-up, or both. Forty-one of 73 identified GEMs (56%)
adhered to the five criteria. Among our findings was that the
standard GEM type, controlling for a variety of structure,
process, and environmental factors, was associated with
shorter index length-of-stay and improved placement (more
home and fewer NH discharges) compared to non-adherent
units. These criteria were intercorrelated. Using the same
dataset, and in narrowing the question to the effectiveness of
VA GEMs with an interdisciplinary team structure, GEMs
with teams (n = 55) were found much more effective than
those without (n = 18), in terms of index length-of-stay
(median 23 days versus 63 days; P = 0.013), home dis-
charge rate (59% versus 31%; P = 0.0004), and nursing
home placement (23% versus 50%; P = 0.001) [36].
231
Of the systematic reviews providing meta-regression
on the components of geriatrics interventions, the only
up-to-date one is by Stuck et al. on the preventive home visit
services [30]. The number of trials of this type has grown
to 18 (only seven were published when they were first
reviewed [31]). The authors found that services providing
more follow-up visits (>9) were effective in reducing nurs-
ing home placement compared with usual care (combined
OR = 0.66; 95% CI: 0.48, 0.92). It is not clear to what ex-
tent this is confounded with greater versus lesser follow-up
time for some trials. Otherwise, frequency of follow-up
as operationalized here seems to capture the dimension
we had defined as control in earlier reviews. Functional
status improvementan outcome not previously reported
in review of non-institutional geriatrics interventionswas
found to be associated with home visit services which
both performed multidimensional assessment and provided
follow-up visits (combined OR = 0.76; 95% CI: 0.64, 0.91).
In sum, many controlled and randomized clinical trials
of geriatrics interventions have been conducted since the
late 1970s, and their results often positive but inconsistent.
The diversity of elderly patients selected, the quite vari-
able organization of these interventions and their financing
(not to mention that of usual care), the inherent com-
plexity of geriatric management making standardization
premature and possibly harmful, the inconsistent measure-
ment and reporting of multiple health and other endpoints,
the difficulty in replicating successful single site studies, all
have limited attempts to move the field forward. System-
atic reviews lend at least some support to the proposition
that geriatric interventions can be effective, as well as gen-
eral support to the association of common organizational
elements (minimum specifications) with positive program
impacts: the selection of frail elderly patients for programs
designed to address elderly patients after acute or subacute
illness episodes (targeting); comprehensive or multidimen-
sional geriatric assessment for all programs; management
with control of treatments, involving long-term follow-up;
and an interdisciplinary team structure appropriate to the
context.
4. Do geriatrics interventions contain costs?
Despite the many forays into clinical investigation of geri-
atric service effectiveness, relatively few directly address ei-
ther costs or charges (see Table 3).3 Where cost has been
studied, it is usually limited to direct per capita outlays on
the part of a third-party (usually public) payer, with little
attention to cohort or total social costs. Further, direct cost
finding may be incomplete for some trials, particularly those
in globally budgeted or capitated systems in which the costs
3 A complete as searched reference list of geriatric intervention trials
reporting costs or charges is available from the author on request.
 232
Table 3
Controlled and randomized clinical trials of geriatrics interventions reporting utilization and cost endpoints
Source/country Intervention type Design/sample size Outcomes/procedural endpoints Utilization impact Cost impact

Naughton et al. Acute geriatrics team (geriatrician, RCT/n = 111 followed to No effect on mortality/discharge Acute LOSb (by 2.1 days Predicted total hospital costs lower
[9]/USA social worker, nurse and PT as hospital discharge disposition but NS) for geriatrics patients than controls
needed) (P = 0.029); lab and pharmacy
costs significantly lower
Stewart et al. Acute care for the elderly (ACE) unit CCT/n = 61 followed to Problems detecteda (P < 0.01) Acute LOSb (6 days vs. 7.1 Overall hospitala per capita charges
[41]/USA discharge discharge drugsb (P < 0.001) days; NS) by US$ 3819; P < 0.01
Applegate et al. Inpatient GEM unit in community RCT/n = 155; stratified Mortalityb ; physical function in NHb placement; community GEM charges per patient much
[10]/USA rehab hospital low/high NH risk to 1 year only low riska tenurea greater (by 73%, P = 0.004).

D. Wieland / Critical Reviews in Oncology/Hematology 48 (2003) 227237

Charges adjusted per year
survived (NS)
Rubenstein et al. Inpatient GEM unit + ambulatory RCT/n = 123 followed to 3 Mortalityb to 2 years; functional NHb use to 1 year; Institutional care costs ND to 3
[11]/USA follow-up in VA system years parameters at 1 yeara community tenure 3 yearsa years for whole cohortlower
among decedents (P = 0.012)
Nikolaus et al. Inpatient GEM unit + discharge Three-group RCT (GEM GEM + DST: physical functiona ; LOSb and NH discharge Total per capita direct costs
[43]/Germany support team (DST) + DST; GEM; usual no mortality difference (P < 0.05); rehospitalization significantly lower for the
care)/n = 545 to 1 year and NH daysb GEM/DST group (by about US$
4000)
Cohen et al. VA inpatient GEM units (multiple RCT/n = 1388 followed to 1 4/8a SF36 subscales at discharge, Indexa LOS and consults; Costs of index hospitalization
[7]/USA centers) year ADLs and physical performance; no NH use lower significantly higher for GEM group
mortality difference and NS trend for post-discharge
costs to be lower, but no difference
to total costs
Fretwell et al. Inpatient geriatric consultation RCT/n = 436 followed to 6 Emotional functiona ; mortality, No LOS difference No difference in hospital charges
[12]/USA service months mental status, physical function
(ND)
Rizzo et al. Multicomponent targeted risk-factor RCT/n = 851; stratified as Delirium in intermediate riskb ; NS No mortality or discharge Costs equivalent in intermediate
[13]/US intervention team (MTI) intermediate/high delirium for high risk difference group; significantly higher in high
risk risk. Authors conclude MTI
cost-effective only for intermediate
risk patients
Kominski et al. Unified psychogeriatric Multicenter RCT/n = 1678 Mental and general health indices Outpatient services used Outpatient costs higher per capita
[42]/USA biopsychosocial evaluation and followed to 1 year (NS) significantly more; inpatient for UPBEAT group (by US$ 1171,
treatment (UPBEAT) discharge bed-days significantly lower P < 0.001); bed-day costs
support team in VA significantly less (by US$ 3027,
P < 0.017). Total costs less in
UPBEAT group (by US$ 1856) but
difference NS
Rubin et al. Hospital-based geriatric clinic RCT/n = 200 followed to 1 IADL functiona and self-reported No difference in NH Total Medicare Pact A/B charges and
[14]/USA discharge support team year health; no ADL, cognitive function, placement; use of home reimbursement greater for controls
mortality differences healtha but NS. Intervention decreased
inpatient charges and reimbursement
Melin et al. Primary geriatric home care team RCT/n = 249 with 6-month IADL function, outdoor mobilitya ; Drugsb ; inpatient daysb ; Total per capita direct care costs
[18]/Sweden supporting hospital discharge follow-up active problemsb outpatient servicesa including team lower in intervention
group by 20% (P = 0.02)
Stewart et al. Hospital-based geriatric home RCT/n = 762 followed 6 Mortalityb Unplannedb readmissions, Hospital-based costs lower by A$
[15]/Australia discharge support team (HBI) months ER visits, total hospital days 490 (NS; P = 0.1) in HBI group;
cost of HBI was A$ 190 per visited
pt; other community costs equivalent
Stessman et al. Home hospitalization (H) Non-equivalent control None reported Hospitalization rates/days in Estimated hospital savings in HH
[16]/Israel group design/base of patients HH plan declined while plan were 5.7 times program costs
in the contrasted insurance control rates increased
plans = 45,500
Tucker et al. Geriatric rehabilitative day hospital RCT/n = 109 with 6 weeks ADLa at 6 weeks not sustained at 6 Use of PT/OTa ; use of Five-month per capita cost in day
[17]/New and 5 months follow-up months; improved mooda (Zung) at inpatient hospitalsb hospital group exceeded control
Zealand 6 months. No difference in cost by about 47% (NZ$ 969)
community tenure
Landi et al. Community-based geriatric 1-year pre-implementation NA Hospitalizationb rate and 27% institutional and outpatient
[44]/Italy assessment and care management vs. 1-year total days cost reduction, about US$ 2700 per

D. Wieland / Critical Reviews in Oncology/Hematology 48 (2003) 227237

post-implementation contrast capita
in multiple sites/n = 1204
Toseland et al. VA outpatient GEM clinic RCT/n = 160 followed 2 No significant mortality or ERb use, outpatient servicesa No significant cost impact to 24
[20]/USA years functional status differences months, but GEM patients incurred
35% more cost in first 8 months,
and 38% less in final 8 months
Keeler et al. Outpatient GEM team + adherence RCT/n = 351 with 15-month Physical functiona ; three SF36 Outpatient visits increased Costs of additional medical services
[19]/USA intervention follow-up subscalesa ; physical performance related to intervention to 5 years estimated at US$ 473 per
testa ; restricted activity daysb patient. Total cost per quality
adjusted life year = US$ 10,600
Cohen et al. VA outpatient GEM clinics RCT/n = 1388 followed to 1 Mentala health per SF36 subscales No difference in LTC days No difference to total costs
[7]/USA (multiple centers) year at 1 year and number of clinic visits
Stuck et al. [21]/ Preventive home visit program RCT stratified by risk of IADLa function in patients at lower NHa admissions among high Trend for increased cost NS overall;
Switzerland employing three public health nurses functional decline/n = 791 baseline risk; no health effects risk health effects were found
with 3-year follow-up among high risk nurse-dependent, resulting in net
cost savings of US$ 1403 per
patient per year in two of three
nurse subgroups. Number needed to
visit to prevent NH admission = 40
Sternberg et al. NH subacute care team (transitional Non-equivalent control Not reported Post-acute TCC LOS shorter Payment rate negotiated for TCC
[22]/USA care center (TCC)) group design/TCC patients than usual contract NH care units 38% less than payouts to
= 1144 vs. controls; 1-year (14.3 days vs. 20.5 days). non-contractual facilities
reporting period
ADL: activities of daily living; CCT: controlled clinical trial; ER: emergency room; GEM: geriatric evaluation and management; IADL: instrumental activities of daily living; LOS: length-of-stay; LTC:
long-term care; NA: not available/applicable; ND: no difference; NS: not significant; NH: nursing home; OT: occupational therapy; PT: physical therapy; RCT: randomized controlled trial; VA: US
Department of Veterans Affairs.
a Increased/more.
b Decreased/fewer/less.

233
234 D. Wieland / Critical Reviews in Oncology/Hematology 48 (2003) 227237
of the experimental programs are unreported or unknown.
As we shall see, another twist on incomplete cost finding
is the neglect of long-term follow-up on utilization and costs
where there has been evidence of improved health outcomes
up to some intermediate point.
Most of the studies reporting on cost endpoints are
framed either in terms of simple cost savings, or what
geriatricians in the 1980s started to call an investment
effect. The cost savings argument, where there has been
evidence for it is of course the simplest to pressas long
as health outcomes (particularly survival) are not better or
worse. More often one reads of no difference in the audited
costs or charges to the study-point, in which case it will
be argued that more appropriate use of services and what-
ever gains have been noted in health outcome (other than
survival) and satisfaction with care justify the intervention
program. In either case, this boils down to an efficiency ar-
gument: less cost for same outcome, or same cost for better
outcome.
When speaking of an investment effect, the clinician
researchers meant investment of resources in the patient
not in the entire cohort of patients (not to mention in the
capital and other costs of establishing geriatrics person-
nel and facilities.) Investment effect was another ver-
sion of the notion that more appropriate services produce
more health wherein the costs of the more appropri-
ate care are offset by less use of expensive institutional
services. In the geriatrics context, that programs target-
ing the frail, deploying comprehensive assessment, etc. by
keeping more people at home at higher levels of function,
would pay for themselves in foregone nursing home
expenditures.
This argument created problems for the uptake of geri-
atrics services from near the beginning of this line of re-
search with the Sepulveda, California, GEM unit study [37].
This was a Veterans Administration inpatient unit that also
provided geriatric ambulatory follow-up care. In the ini-
tial paper, we reported significantly improved functional
health outcomes, and less nursing home and hospital use
to 1-year. This resulted in an estimated net per capita sav-
ings of slightly less than US$ 1000 (about 5%) for GEM
care. However, significantly more GEM patients survived
the year, implying of course a greater expenditure for the
entire cohort. However, there was a survival-adjusted per
capita per patient-year survived of over US$ 5200 (19%)
less than usual care.
Soon afterward, Applegate et al. established a GEM in a
non-VA, community rehabilitation hospital that was in many
respects modeled on the Sepulveda unit [10]. This GEM
however did not provide post-discharge follow-up. In his
randomized trial, Applegate prospectively stratified patients
into high nursing home risk, and elderly patients with good
rehabilitation potential categories. At 1 year, there was over-
all less nursing home use and more time in the community in
the GEM group. However, health outcomes were improved
only in the low-risk stratum: these patients had significantly
improved functional status and survival relative to controls.
Unfortunately, per capita charges were significantly higher
in the GEM group (by 73%, nearly US$ 12,000 more). Ap-
plegate performed the same kind of survival adjustment, with
the result that the difference was no longer statistically sig-
nificant, but still substantial. The only way to get the costs
equivalent was to calculate the expenditures to produce a
community day in the follow-up year.
So the good news of potentially improved survival
through geriatrics intervention threatened the message of
the offset argument: the inputs may be less expensive per
capita to the point of improving survival, but more people
alive often means more resources consumed. Moreover,
as the counter argument goes, increased costs in the con-
trol group may reflect the well-known high cost of dying.
If more of the geriatrics patients are alive at some point
of follow-up, will they not be as expensive to care for
as controls when they eventually enter their pre-terminal
phase? In which case any per capita cost advantage or
equivalence will disappear, and the cohort cost will likely
be much higher. To address this, we examined survival,
cost and utilization in the Sepulveda study [11], find-
ing that per capita direct care costs for the GEM group
were still not significantly higher even after the survival
curves of both group had converged (at about 40% sur-
vivorship at 3 years). To look directly at the cost of dying
issue, we performed a mortality follow-back on institu-
tional care costs in GEM and control decedents final
year. Costs were significantly lower in GEU decedents
(by 20% or nearly US$ 7000), mostly attributable to less
hospital utilization. The important implication of this is
that the Sepulveda GEU/GEM had not simply delayed
expenditures.
It is unfortunate that most of the work on CGA-based
intervention outcomes and costs has been done on GEMs,
because the GEM approach has not disseminated in US
hospitals, for a variety of reasons related to organiza-
tion of care, training and financing [35,38]. However, the
point concerning the impact of CGA-related interven-
tions on the costs of dying should not be lost, because
this approach to considering their cost-effectiveness may
be more appropriate overall, and in fact have more im-
pact on health policy discourse and decision-making.
The evidence for this is in the quasi-experimental eval-
uation of the Program of PACE model, also in the US.
Here, too, significant health effects of integrated geri-
atric care have been supported [24], including a survival
effect [39], with per capita cost savings or neutrality es-
timated for the Medicare and Medicaid programs in the
first years of follow-up. As this program has gone from
demonstration to federal provider status and built up so
that 27 distinct programs now operate in 16 states, total
cohort cost is not an issue even in the macro-allocation
discourse. In fact, policy-makers are much more in-
terested in per capita end-of-life utilization and costs,
which for PACE may be at least as favorable versus
 D. Wieland / Critical Reviews in Oncology/Hematology 48 (2003) 227237 235

usual care as was suggested in the early GEU study disease management interventions (e.g. geriatric oncology
[24,40]. services).
The problems for disseminating effective geriatrics ser-
vice models created by fragmented systems of reimburse-
ment are exemplified in several studies. In the US, Medi-
5. Conclusion
care hospital-based acute management and discharge sup-
port programs tend to lower length-of-stay and use of lab-
In this review, I have attempted to define CGA-based in-
oratory and pharmacy services [9,13,14,41,42], resulting in
terventions by their common and normative components, as
lower charges. Exactly how reducing charges effects hospi-
well as addresses questions of their effectiveness and costs
tal profitability, given the implications for reimbursements
with reference to individual trials and systematic reviews.
and hospital costs, is not clear. At any rate, systems in which
On balance, the trial evidence lends support to the proposi-
there can be recoupment of investments in geriatric acute,
tion that geriatric interventions can be effective in improv-
post-, and subacute care may be more likely to build and sus-
ing some health and functional parameters and extending
tain these interventions. Examples are programs in globally
community tenure. The results however are not uniformly
budgeted systems like the VA or managed care organizations
positive. Much of this outcome variability seems related to
[7,20,22,42], and programs outside the US [15,16,18,43,44].
the quality of implementation of the same normative com-
Such systems of better integrated financing and provisioning
ponents with which geriatrics interventions are identified.
are also a more likely home for efficient community based
What was made clear in the published meta-regression anal-
programs (e.g. [21]).
yses is that targeting the frail, an interdisciplinary team struc-
The question at the beginning of the present section
ture with clinical control of care, and long-term follow-up,
concerns cost-effectiveness of geriatric intervention. Most
tend to be associated with effective programs. Trials that
of the studies abstracted in Table 3 are oriented only to
have addressed costs are fewer. Given this, evidence for
cost-efficiency. As far as the trial literature goes, there are
cost-effectiveness is more tenuous. Such evidence as ex-
few studies of cost-effectiveness, wherein the effects of
ists, with some exceptions (e.g. [10]), supports the notion
geriatric intervention are compared to usual care, em-
that these interventions can meet this social imperative. This
ploying cost-effectiveness ratios (marginal expenditure to
was seen to apply to limited shorter-term interventions such
produce unit measures of health outcome). An exception in
as acute-phase management in which efficiencies may have
Table 3 is the study by Keeler et al. [19], who examined the
more to do with cost savings than dramatic outcome im-
cost-effectiveness of an outpatient GEM team employing an
pact, as well as more comprehensive, long-term programs.
adherence enhancement intervention. Of the positive out-
Among the latter, it was shown that there is some evidence
comes in that trial, the authors used data concerning relative
supporting an investment effect, and that programs vested
gains in the 10-item physical function subscale of the SF-36
with more control and providing more follow-up over the
to calculate differences in health status in terms of quality
long-term may be more likely to have such an effect, whether
of well-being utilities, and eventually quality adjusted life
they be preventive home visit models [21], or more inte-
years (QALYs). The total cost per QALY was reckoned
grated, all-inclusive approaches [24]. It is unlikely that the
at US$ 10,600, which was considered by the authors as
widespread emergence of geriatrics interventions within and
relatively cost-effective. The argument for/against such as
as systems of care will be hindered by these uncertainties,
investment versus using dollars in other (usually younger,
as population aging and political shifts bring geriatrics more
more functional) populations relies on the sense of values
into the mainstream. Still, there is much room for clini-
and distributive justice in the audience. Historically, it has
cal and scientific advance as we move to better understand
been hard for geriatricians to press this kind of argument
what geriatrics interventions do well and in whom. The next
[45,46].
1015 years should be a most fruitful time of discovery in
Population aging brings with it shifts in health politics and
this regard.
policy. It is conceivable that we will approach a social con-
sensus on the goals of geriatric care; that perceived need for
Reviewers
cost-effectiveness trials of complex packages of care with
their limited generalizability and other problems will be re- Dr. Niels Neymark, Coordinator, Health Economics
placed by continuous quality improvement processes applied Unit, EORTC, Avenue E. Mounier 83, B-1200 Brussels,
in a growing base of geriatric services, followed up by more Belgium.
focused and efficient experimental and quasi-experimental Chad Boult, M.D., M.P.H., M.B.A., Professor and Di-
studies. Questions of cost-effectiveness might then begin to rector, Department of Health Policy and Management,
focus on simpler issues, e.g. concerning treatment alterna- Lipitz Center for Integrated Health Care, Johns Hop-
tives within geriatric systems of care (e.g. strength train- kins Bloomberg School of Public Health, Baltimore, MD
ing versus aerobic exercise for knee osteoarthritis [47]), 21205-1996, USA.
or the targeting of frail elderly for packages combining Laurence Rubenstein, M.D., M.P.H., Professor of
geriatric and acute specialty (e.g. gerorthopedic units) or Medicine, VA Medical Center (11-E), UCLA School of
236 D. Wieland / Critical Reviews in Oncology/Hematology 48 (2003) 227237
Medicine, 16111 Plummer Street, Sepulveda, CA 91343,
USA.
References
[1] Rubenstein LZ. An overview of comprehensive geriatric assessment:
rationale, history, program models, basic components. In: Rubenstein
LZ, Wieland D, Bernabei R, editors. Geriatric assessment technology.
Milan: Kurtis; 1995.
[2] Warren MW. Care of the chronic aged sick. Lancet 1946;1:841
3.
[3] Wieland D, Hedrick SH, Rubenstein LZ, Buchner D, Reuben D,
Harker J. Inpatient geriatric evaluation and management units: or-
ganization and care patterns in the Department of Veterans Affairs.
Gerontologist 1994;34:6527.
[4] Wagner EH, Austin BT, Hindmarsh M, Schaefer J, Bonomi A. Im-
proving chronic illness care: translating evidence into action. Health
Affairs 2001;20(6):6478.
[5] Bodenheimer T. Long-term care for the frail elderlythe On Lok
model. N Engl J Med 1999;341:13248.
[6] Reuben DB, Borok GM, Wolde-Tsadik G, Ershoff DH, Fishman
LK, Ambrosini VL, et al. A randomized trial of comprehensive
geriatric assessment in the care of hospitalized patients. N Engl J
Med 1995;332:134550.
[7] Cohen HJ, Feussner JR, Weinberger M, et al. A controlled trial of
inpatient and outpatient geriatric evaluation and management. N Engl
J Med 2002;346:90512.
[8] Campbell M, Fitzpatrick R, Haines A, et al. Framework for design
and evaluation of complex interventions to improve health. Br Med
J 2000;321:6946.
[9] Naughton BJ, Moran MB, Feinglass J, Falconer J, Williams ME.
Reducing hospital costs for the geriatric patient admitted from
the emergency department: a randomized trial. J Am Geriatr Soc
1994;42:10459.
[10] Applegate WB, Graney MJ, Miller ST, Elam JT. Impact of a geriatric
assessment unit on subsequent health charges. Am J Public Health
1991;81:13026.
[11] Rubenstein L, Josephson K, Harker J, Miller DK, Wieland D. The
Sepulveda GEU Study revisited: long-term outcomes. Aging (Milano)
1995;7:2127.
[12] Fretwell MD, Raymond PM, McGarvey ST, et al. The Senior Care
Study: a controlled trial of a consultative/unit based geriatric as-
sessment program in acute care. J Am Geriatr Soc 1990;38:1073
81.
[13] Rizzo J, Bogardus S, Leo-Summers L, Williams CS, Acampora D,
Inouye SK. Multicomponent targeted intervention to prevent delirium
in hospitalized older patients: what is the economic value? Med Care
2001;39:74052.
[14] Rubin CG, Sizemore MT, Loftis PA, Adams-Huet B, Anderson RJ.
The effect of geriatric evaluation and management on Medicare
reimbursement in a large public hospital: a randomized clinical trial.
J Am Geriatr Soc 1992;40:98995.
[15] Stewart S, Pearson S, Luke CG, Horowitz JD. Effects of home-based
intervention on unplanned readmissions and out-of-hospital deaths.
J Am Geriatr Soc 1998;46:17480.
[16] Stessman J, Ginsburg G, Hammerman-Rozenberg R, et al. Decreased
hospital utilization by older adults attributable to a home hospital-
ization program. J Am Geriatr Soc 1996;44:5918.
[17] Tucker MA, Davison JG, Ogle SJ. Day hospital rehabilitation
effectiveness and cost in the elderly: a randomized controlled trial.
Br Med J 1984;289:120912.
[18] Melin A, Hakansson S, Bygren L. The cost-effectiveness of rehabil-
itation in the home: a study of Swedish elderly. Am J Public Health
1993;83:35662.
[19] Keeler E, Robalino D, Frank J, et al. Cost-effectiveness of outpatient
geriatric assessment with an intervention to increase adherence. Med
Care 1999;37:1199206.
[20] Toseland RW, ODonnell JC, Englehardt JB, Richie J, Jue D, Banks
SM. Outpatient geriatric evaluation and management: is there an
investment effect? Gerontologist 1997;37:32432.
[21] Stuck AE, Minder C, Peter-West I, et al. A randomized trial of
in-home visits for disability prevention in community-dwelling older
people at low and at high risk for nursing home admission. Arch
Intern Med 2000;160:97786.
[22] von Sternberg T, Hepburn K, Cibuzar P, et al. Post-hospital subacute
care: an example of a managed care model. J Am Geriatr Soc
1997;45:8791.
[23] Wagner EH, Grothaus LC, Sandhu N, et al. Chronic care clinics for
diabetes in primary care: a system-wide randomized trial. Diabetes
Care 2001;24:695700.
[24] White A, Abel Y, Kidder D. Evaluation of the program of all-inclusive
care for the elderly (PACE) demonstration: a comparison of the PACE
capitation rates to projected costs in the first year of enrollment.
Final Report to HCFA, Contract #500-01-0027. Cambridge: Abt
Associates; 1998.
[25] Forster A, Young J, Langhorne P. Systematic review of day hospital
care for elderly people. Br Med J 1999;318:83741.
[26] Parker G, Bhakta P, Katbamna S, et al. Best places of care for old
people after acute and during subacute illness: a systematic review.
J Health Serv Res Policy 2001;5:17689.
[27] Parkes J, Shepperd S. Discharge planning from hospital to home.
Cochrane Database Syst Rev 2000;4:CD000313.
[28] Shepperd S, Iliffe S. Hospital at home vs. in-patient hospital care.
Cochrane Database Syst Rev 2000;2:CD000356.
[29] Hyde CJ, Robert IS, Sinclair AJ. The effects of supporting discharge
from hospital to home in older people. Age Ageing 2000;29:271
9.
[30] Stuck A, Egger M, Hammer A, Minder CE, Beck JC. Home visits
to prevent nursing home admission and functional decline in el-
derly people: systematic review and meta-regression analysis. JAMA
2002;287:10228.
[31] Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Com-
prehensive geriatric assessment: a meta-analysis of controlled trials.
Lancet 1993;342:10326.
[32] Wieland D, Rubenstein LZ. What do we know about targeting in
geriatric evaluation and management (GEM) programs? Aging Clin
Exp Res 1996;8:297311.
[33] Fletcher A. Multidimensional assessment of elderly people in the
community. Br Med Bull 1998;54:94560.
[34] Landefeld CS, Palmer RM, Kresevic DM, et al. A randomized trial
of care in a hospital medical unit especially designed to improve
the functional outcomes of acutely ill older adults. N Engl J Med
1995;332:133844.
[35] Wieland D, Rubenstein LZ, Hedrick SC, Reuben DB, Buchner DM.
Inpatient geriatric evaluation and management (GEM) units in the
veterans health system: diamonds in the rough? J Gerontol Med Sci
1994;49:M195200.
[36] Wieland D, Kramer BJ, Waite MS, Rubenstein LZ. The interdisci-
plinary team in geriatric care. Am Behav Sci 1996;39:65564.
[37] Rubenstein LZ, Josephson KR, Wieland GD, English P, Sayre J,
Kane RL. Effectiveness of a geriatric evaluation unit: a randomized
clinical trial. N Engl J Med 1984;311:166470.
[38] Lavizzo-Mourey RJ, Hillman AL, Diserens D, et al. Hospitals mo-
tivations in establishing or closing geriatric evaluation and manage-
ment units: diffusion of a new patient-care technology in a changing
health care environment. J Gerontol Med Sci 1993;48:M7883.
[39] Chatterji P, Burstein NR, Kidder D, White AJ. Evaluation of the
program of all-inclusive care for the elderly (PACE) demonstration:
the impact of PACE on participant outcomes. Final Report to HCFA,
Contract #500-96-0003/TO4. Cambridge: Abt Associates; 1998.
 D. Wieland / Critical Reviews in Oncology/Hematology 48 (2003) 227237
[40] Temkin-Greener H, Mukamel DB. Predicting place of death in the
program of all-inclusive care for the elderly (PACE): participant vs.
program characteristics. J Am Geriatr Soc 2002;50:12535.
[41] Stewart M, Suchak N, Scheve A, et al. The impact of a geriatrics
evaluation and management unit compared to standard care in a
community teaching hospital. Md Med J 1999;48:627.
[42] Kominski G, Andersen R, Bastani R, et al. UPBEAT: the impact
of a psychogeriatric intervention in VA medical centers. Med Care
2001;39:50012.
[43] Nikolaus T, Specht-Leible N, Bach M, Oster P, Schlierf G. A random-
ized trial of comprehensive geriatric assessment and home interven-
tion in the care of hospitalized patient. Age Ageing 1999;28:54350.
[44] Landi F, Onder G, Russo A, et al. A new model of integrated
home care for the elderly: impact on hospital use. J Clin Epidemiol
2001;54:96870.
[45] Avorn J. Benefit and cost analysis in geriatric care: turning age
discrimination into health policy. N Engl J Med 1984;310:1294301.
[46] Leidl R, Stratmann D. Economic evaluation is essential in healthcare
for the elderly. A viewpoint. Drugs Aging 1998;13:25562.
[47] Sevick M, Bradham D, Muender M, et al. Cost-effectiveness of
aerobic and resistance exercise in seniors with knee osteoarthritis.
Med Sci Sports Exerc 2000;32:153440.
237
Biography
Dr. Darryl Wieland received his Ph.D. in anthropology
from the University of Rochester in 1982, and Masters
degree in public health from UCLA in health services in
1983. Dr. Wieland is research director at the South Car-
olina Consortium for Geriatrics, and professor at Division
of Geriatrics, Department of Medicine, at the University of
South Carolina School of Medicine. He formerly held po-
sitions as associate professor in geriatrics and gerontology
at the UCLA School of Medicine, senior research scientist
at the Sepulveda Geriatric Research, Education and Clin-
ical Center, and research director, Beverly Foundation, in
Pasadena. Dr. Wieland is a fellow of the American Geri-
atrics Society, the Gerontological Society of America, and
the Society for Applied Anthropology. His research interests
include comprehensive geriatric assessment, long-term care,
cost-effectiveness, and clinical epidemiological methods.