Overlooked barriers to implementation of geriatric assessment

In this issue of the journal, Magnuson et al. provide a comprehensive review of available geriatric assessment (GA) tools and their impact on outcomes for solid tumors and hematologic malignancies. In addition, the authors provide a clear guide for clinicians to help understand the importance of GA and management.¹

An assumption inherent in the GA is that improvement in outcomes is driven by modifications in treatment delivery or implementation of features to make activities of daily living safer. In other words, GA-guided management² or GA-driven intervention,³ rather than simply performing the GA, is what leads to outcome improvement. These modifications are implemented using a multidisciplinary team of geriatric trained specialists. Examples include occupational therapists to improve home safety, physical therapists to improve gait and balance, pharmacists to review home medications and adjust based on anticipated adverse drug interactions, dietitians to improve nutrition, etc. Most of the studies included showed benefit, either in survival, reduced toxicity, improved quality of life, or cost effectiveness.

These observations led to the development of an American Society of Clinical Oncology guideline recommending GA-guided management of cancer treatment in elderly adults.⁴ However, it is widely recognized that this tool is underused by practicing oncologists.⁵ The whys have been explored by Magnuson et al. and others^{5, 6} and included the belief that the GA was too cumbersome in addition to the perception that it added little or no value. Based on these assumptions, making assessment tools more efficient and educating providers about their evidence-generated benefits have been the focus of efforts to improve GA use. To encourage greater uptake of the tool, Magnuson and co-authors detail ways to educate providers and simplify the GA.

What is not discussed that may be an important root cause of poor uptake of GA is resource scarcity, which takes two forms. The first is the lack of available services to support GA-modified treatment. Substantial numbers of communities, particularly in rural sites, do not have consistent—if any—access to the specialists required to modify treatment in a GA-guided manner. These practices almost certainly do not have geriatricians or geriatric-trained nurse practitioners; and they may not have physical therapists, occupational therapists, chemotherapy-dedicated pharmacists, or even social workers. Rural sites particularly often have one oncology provider whose job is to meet all the needs of every oncology patient in their practice. This distributive inequity of resources⁷ has always existed and will continue to plague rural communities. In this context, even if one performed a GA, opportunities to make care delivery safer or less toxic would be challenging in the absence of necessary ancillary services.

The second resource scarcity comes from the constraints on the oncologist's time, which is more universal. Williams et al. suggested that more frequent toxicity checks would help improve GA-based outcomes even in resource-limited communities.⁴ However, this overlooks the finding that the centrally important resource, oncologist time, is already in short supply everywhere, particularly in underserved communities. The numbers of those requiring cancer care continue to increase because of an aging US population and the increasing incidence of cancer in young adults. Meanwhile, the number of oncologists in the workforce is not increasing to keep up with demands. In an environment in which oncologists are asked to address pain at every visit, manage distress, mitigate financial toxicity, and actually treat the cancer, adding another requirement to oncologist visits is likely to generate much resistance. As the saying goes, you can only get so much blood from a stone. The integration of geriatric principles into oncology will face problems of inertia, especially in busy clinics. However, short cuts will probably not work. Simple, easily administered GA screens might seem attractive in resource-limited areas, but results have been inconsistent.⁷ In addition, resource-limited areas will not have the support systems that the GA may require to realize optimal care of the elderly oncology patient.

The important question then becomes: How do we help improve the ability of resource-challenged practitioners to implement the changes required by GA? Writing guidelines and encouraging GA use without addressing this fundamental problem will leave GA underused. If you cannot act on test results, why perform them? And writing guidelines without addressing this fundamental resource problem will leave patients with disappointed expectations and may expose oncologists working in resource-challenged communities to liability.

This is not to say that we should abandon GA. Telehealth has been successful in many aspects of oncology, from surveillance to toxicity monitoring, and could be used for geriatric consultation and management. Our national organizations (e.g., the American Society of Clinical Oncology and the American Cancer Society) could help create a panel of nationally credentialed geriatricians available for teleconsultation that would address this aspect of GA. However, this assumes that there are enough geriatricians who are willing and able to meet the expanding needs of an ever-growing elderly population. A more difficult problem to solve is how to assemble a multidisciplinary team to actualize GA recommendations, including broader access to occupational and physical therapy evaluation and management, which require in-person, hands-on visits. Perhaps a novel solution to this manpower issue would be to help create a new paraprofessional field, geriatric assessment implementation technicians (GAITs). Such GAITs would be lay people who undergo a relatively brief, focused training period followed by certification, similar to lay navigators. These individuals could be trained to do in-home evaluations and make changes necessary for the safe implementation of chemotherapy and could be deployed to underserved and rural communities. Designed correctly, this could be an attractive and useful career option in communities that are lacking economic opportunities and could provide a solution to the growing need represented by our aging population. These two elements, telehealth geriatrics supporting local physicians and GAITs complimenting telehealth occupational therapy/physical therapy, will require additional funding and would require implementation studies to determine whether and/or how these enhancements improve outcomes. Envisioning the resources needed to support these initiatives may seem daunting. However, ignoring the problem will not make it go away.

If we want to improve the use of GA in all oncology practices, educating oncologists and simplifying the tool is not enough. We must help enable under-resourced practices to implement GA-based changes, and we need to bring the required specialty practices to the rural environment. Remembering the needs of underserved communities will be vital to the success of any and all guidelines that continue to roll out.