Interventions to improve health care provider implementation and patient adherence of patients to recommendations on geriatric assessment and management in older adults: A scoping review protocol

Abstract

The world population is aging. Comprehensive Geriatric assessment (CGA) has been proven to improve the well-being of older adults. However, evidence suggests not all clinicians implement these recommendations in their practice; nor do all patients adhere to them. Currently, there is no up-to-date review of interventions that can improve older adults’ adherence to CGA recommendations and health care provider/clinician implementation of those recommendations. The objective of this scoping review protocol is to describe the methodology of the scoping review with the aim to identify interventions that have been tested to improve adherence to CGA recommendations. We will use the Arksey and O’Malley framework and subsequent extension by Levac and colleagues to complete the scoping review. We searched OVID MEDLINE, OVID Embase, EBSCO CINAHL, APA PsychInfo, and Cochrane CENTRAL databases from inception to November 14, 2024, and will include a review of reference lists of included studies. Studies eligible for inclusion are studies of any design that examined one or more interventions aiming to improve clinician implementation of and patient adherence to CGA in any clinical setting. We will use standard methods for study selection, data abstraction, assessment of methodological quality of individual studies, and data synthesis. Results will be analyzed and reported using descriptive numerical summaries and narrative analysis. Findings from the scoping review will be published in a manuscript and presented at scientific conferences.

Introduction

The world population is aging - the World Health Organization (WHO) estimates that by 2030 one in six persons in the world will be 60 years and over [1]. It is becoming increasingly important to address the needs of an aging population, thus the WHO recommends person-centered care that prioritizes the older adult’s needs and helps them achieve their life goals [2]. Comprehensive Geriatric Assessment (CGA) is a person-centered intervention that uses a holistic approach, which has been shown to improve the well-being of older adults [3–6].

CGA has not been widely implemented in many clinical settings thus far due to a lack of resources such as trained health care providers who have sufficient time to conduct CGA. For CGA to reach maximal benefit in improving health and quality of life, adherence of older adults receiving geriatric care to clinicians’ recommendations is crucial. Adherence to long-term therapies has been defined by the World Health Organization as “the extent to which a person’s behaviour- taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider” [7]. There has been only one narrative review reporting on rates of patient adherence to CGA in community-based clinics and the author reported that the older adults adherence rate to clinician recommendations ranged from 46 to 76% [8]. However, to the best of our knowledge there has not been a review of interventions aiming to improve patient adherence to CGA recommendations [8].

There is a need to better understand interventions aiming to improve the implementation of CGA recommendations by clinicians and patient adherence to those recommendations by older adults in clinical settings where the majority of patients are older adults and could therefore benefit from CGA. Furthermore, future studies that incorporate CGA as part of the clinical intervention could benefit from evidence on how CGA can be optimized in clinical settings where CGA is used. Therefore, the aim of this protocol article is to describe the methodology of a scoping review that will summarize interventions tested in any clinical setting to improve the implementation by health care providers and patient adherence to GCA. Scoping reviews are a form of knowledge synthesis that addresses exploratory research questions to map key concepts, types of evidence, and gaps within specific areas or fields [9]. Given our broad research question, a scoping review is appropriate and will best accomplish the aim of identifying and mapping interventions aimed at increasing implementation of CGA recommendations by clinicians and older adults’ adherence to CGA recommendations while exploring if there is sufficient evidence to support a future systematic review [10].

Methods

We will follow the Arksey and O’Malley scoping review framework [11] and subsequent extension by Levac et al [12]. We will follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) scoping review extension (PRISMA-ScR) [13] for reporting the scoping review (see S1 File: PRISMA-P Checklist). We developed this protocol using the Open Science Framework scoping review protocol guidelines [14].

Eligibility criteria

We structured the inclusion criteria based on PICOSL (population, intervention, comparison, outcome, study design, language) elements.

* Population: older adults with any diagnosis from any country and any clinical setting, as well as their care partners and health care providers.

* Intervention: any intervention targeting clinicians’ implementation of and older patient adherence to CGA.

* Comparison: any comparator group/population if available.

* Outcome: Improvement of clinicians’ implementation of and older patient adherence to CGA.

* Study design: any type of peer-reviewed publication (full-text articles and conference abstracts) reporting on any type of study design (even case reports and case series) assessing interventions for improving clinician implementation and older patient adherence to CGA.

* Language: Studies published in English, French, Dutch or German because the research team can assess manuscripts in these languages.

We will exclude duplicate abstracts/full-texts, reviews, editorials, and commentaries.

Information sources and search strategy

Our health sciences librarian (APA) completed a literature search using the following databases: OVID MEDLINE, OVID Embase, EBSCO CINAHL, APA PsycINFO and Cochrane CENTRAL from inception to November 14, 2024. The search was peer-reviewed using the Electronic Search Strategies (PRESS) checklist [15] by another librarian. We will supplement the search with a manual review of reference lists of included studies. The initial search was conducted using OVID MEDLINE please see Table 1 for the MEDLINE search strategy. All searches were translated to other databases using the appropriate controlled vocabulary. Please see S2 File Search strategies used November 14 2024 S1–S4 Tables in S2 File for the search strategies used for Embase, CINAHL, PsycInfo and Cochrane Central.

[Figure omitted. See PDF.]

Study selection

We will first remove duplicate abstracts using Endnote then import the remaining abstracts into Covidence. In Covidence, we will use the deduplication function to further remove duplicates. We will use a two-step study selection process. First, two independent reviewers will read resultant titles and abstracts for eligibility using Covidence software. If there is no abstract but the title is relevant, it will be selected for full-text review. Irrelevant titles and titles and without abstracts will be excluded in the selection process. Disagreements will be resolved by a third reviewer using Covidence. Next, full texts of the resultant studies will be read and reviewed according to eligibility criteria by two independent reviewers. Disagreements during full-text selection will be resolved by a third reviewer. Articles not available at the University of Toronto library will be requested through the Interlibrary Loan system (https://onesearch.library.utoronto.ca/request-items-other-institutions-ill).

Data charting and extraction

We will abstract data using a Microsoft Excel spreadsheet designed by LF and MP that includes our PICOSL elements. Data on general study characteristics (authors, publication year, title, journal, country, study design, randomization method, study population, study description, study results with regard to adherence and other outcomes) and intervention characteristics using the Template for Intervention Description and Replication (TIDieR) Checklist [16] will be collected by two independent reviewers.

Consistent with recommendations from Levac et al. [12], two reviewers will pilot test the data collection sheet during the initial data extraction process (an estimated two studies) to ensure it is consistent with the research question and purpose. We will resolve discrepancies between the two reviewers by consensus with a third reviewer. For any missing or unclear information, reviewers will e-mail the study authors to request or clarify information. If the authors do not reply within 2 weeks, a reminder email will be sent. If it is not possible to obtain the missing information from the study authors, data will be coded accordingly (“not reported”).

While a quality assessment of the included studies is optional for scoping reviews [13], we have chosen to include a quality assessment to be able to better summarize the available evidence identified in this review. The Mixed Methods Appraisal Tool (MMAT) version 2018 [17,18] uses the same quality assessment criteria for different types of study designs, which aligns well with this review where we will include all study designs that have been used to study an intervention to increase patient adherence to CGA. We will conduct quality assessment using the MMAT concurrently with the data abstraction for each study. Two reviewers will independently complete the quality assessment and disagreements will be resolved by consensus with a third reviewer. No study will be excluded based on the quality assessment.

Summarizing, collating, and reporting results

We will follow the PRISMA scoping review guidelines [13] for reporting results and include a PRISMA flow diagram to graphically depict the study selection process. We will present the results of methodological quality assessment in a table. In accordance with principles of narrative synthesis, which is the mainstay of data synthesis in scoping reviews [10]), we will analyze and report extracted data based on their models of presentation in included primary studies.

Discussion

CGA can improve well-being for older adults receiving care in clinical settings, however patient adherence to those recommendations is sub-optimal. We anticipate that even better outcomes can be achieved by CGA if patient adherence to clinical recommendations and health care provider/clinician implementation of CGA is optimized. To our knowledge, there has not been a systematic search for interventional studies aimed at improving patient adherence to CGA and health care provider/clinician implementation of CGA. The results of the scoping review will be relevant for clinicians using CGA in any setting, as there is a growing interest with the aging world population to use CGA effectively to improve outcomes for more vulnerable older adults [19].

This scoping review will not involve patients or the collection of primary research, therefore ethical approval is not required. Typically, as part of the Arksey and O’Malley scoping review framework, consultation with stakeholders is recommended [11]. As part of this review process, we will not complete a consultation as that will be done as part of the next study by our team.

Dissemination of the results of the scoping review to the broad scientific community will take place through the publication of a peer-reviewed article and presentation of results at scientific and clinical conferences.

A strength of our scoping review is a comprehensive search approach including multiple databases, multiple languages and searching for studies conducted in any clinical setting (specialized and non-specialized). A limitation is that some of the interventions that we will identify may be older and less relevant to the current clinical setting. It is important to understand what interventions have been tested so far so we can learn from previous studies. Another potential limitation is that we anticipate most studies will be from High Income Countries which will limit the generalizability of the findings to other parts of the world. Lastly, while CGA is an intervention for older adults, studies may be heterogeneous in terms of the older adult definition used across studies.

Conclusion

This scoping review protocol provides an overview of the methodology of a scoping review that will provide a summary of the literature on interventions used to improve implementation by health care providers of and patient adherence to CGA recommendations when caring for older adults in any clinical setting. That information will be useful for health care providers to improve the implementation of CGA in their clinics.

Dr. Puts is the guarantor of the scoping review protocol.

Supporting information

S1 File. PRISMA-P Checklist.

https://doi.org/10.1371/journal.pone.0317177.s001

(DOCX)

S2 File. Search strategy for all databases.

https://doi.org/10.1371/journal.pone.0317177.s002

(DOCX)

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Citation: Freeman L, Smith A, Ku N-W, Ayala AP, Bennie F, Berger A, et al. (2025) Interventions to improve health care provider implementation and patient adherence of patients to recommendations on geriatric assessment and management in older adults: A scoping review protocol. PLoS ONE 20(1): e0317177. https://doi.org/10.1371/journal.pone.0317177

About the Authors:

Laura Freeman

Contributed equally to this work with: Laura Freeman, Ainslee Smith

Roles: Methodology, Writing – original draft

Affiliation: Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada

Ainslee Smith

Contributed equally to this work with: Laura Freeman, Ainslee Smith

Roles: Methodology, Writing – original draft

Affiliation: Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada

ORICD: https://orcid.org/0009-0004-2307-478X

Nai-Wen Ku

Roles: Conceptualization, Funding acquisition, Writing – review & editing

Affiliation: Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada

Ana Patricia Ayala

Roles: Conceptualization, Methodology, Writing – review & editing

Affiliation: Gerstein Information Science Centre, University of Toronto, Toronto, Ontario, Canada

Fay Bennie

Roles: Conceptualization, Funding acquisition, Writing – review & editing

Affiliation: Older Adult and Support Team Members, Toronto, Ontario, Canada,

Arielle Berger

Roles: Conceptualization, Methodology, Writing – review & editing

Affiliation: Toronto Grace Health Centre, and University of Toronto Department of Medicine, Toronto, Ontario, Canada

Tyler R. Chesney

Roles: Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Affiliation: Department of Surgery, Unity Health, Toronto, Ontario, Canada

ORICD: https://orcid.org/0000-0002-2295-6869

Ploa Desforges

Roles: Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Affiliation: Department of Geriatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada

Kristen Haase

Roles: Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Affiliation: UBC School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada

Jennifer Jones

Roles: Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Affiliation: Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada

Annie Lacerte

Roles: Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Affiliation: Department of Geriatrics, Université de Sherbrooke, Sherbrooke, Quebec, Canada

Caroline Mariano

Roles: Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Affiliation: BC Cancer Agency, Vancouver, British Columbia, Canada

Rajin Mehta

Roles: Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Affiliation: Division of Geriatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

Ines Menjak

Roles: Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Affiliation: Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

Johanne Monette

Roles: Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Affiliation: Division of Geriatric Medicine, Jewish General Hospital, Montreal, Quebec, Canada

Richard Norman

Roles: Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Affiliation: Toronto Grace Health Centre, and University of Toronto Department of Medicine, Toronto, Ontario, Canada

Nicholas Legacy

Roles: Methodology, Writing – review & editing

Affiliation: Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada

Maryjo Antonio

Roles: Methodology, Writing – review & editing

Affiliation: Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada

ORICD: https://orcid.org/0009-0004-1564-0382

Eric Pitters

Roles: Conceptualization, Funding acquisition, Writing – review & editing

Affiliation: Older Adult and Support Team Members, Toronto, Ontario, Canada,

Anne Stephens

Roles: Conceptualization, Funding acquisition, Writing – review & editing

Affiliation: Older Adult and Support Team Members, Toronto, Ontario, Canada,

Douglas Stephens

Roles: Conceptualization, Funding acquisition, Writing – review & editing

Affiliation: Older Adult and Support Team Members, Toronto, Ontario, Canada,

ORICD: https://orcid.org/0009-0007-9801-5743

Doreen Wan-Chow-Wah

Roles: Conceptualization, Funding acquisition, Methodology, Writing – review & editing

Affiliation: Division of Geriatric Medicine, McGill University Health Centre, Montreal, Quebec, Canada

Camilla L. Wong

Roles: Conceptualization, Funding acquisition, Writing – review & editing

Affiliation: Department of Medicine, Unity Health, Toronto, Ontario, Canada

Shabbir M.H. Alibhai

Roles: Conceptualization, Funding acquisition, Methodology, Project administration, Writing – review & editing

Affiliation: Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada

Martine Puts

Roles: Conceptualization, Funding acquisition, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

E-mail: [email protected]

Affiliation: Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada

ORICD: https://orcid.org/0000-0002-0710-1854

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References

1. The World Health Organization. Ageing and health: The World Health Organization; 2024 [cited 2024 Oct 1. ]. Available from: https://www.who.int/news-room/fact-sheets/detail/ageing-and-health

2. The World Health Organization. WHO’s work on the UN Decade of Healthy Ageing: The World Health Organization; 2024. Available from: https://www.who.int/initiatives/decade-of-healthy-ageing

3. Anwar MR, Yeretzian ST, Ayala AP, Matosyan E, Breunis H, Bote K, et al. Effectiveness of geriatric assessment and management in older cancer patients: a systematic review and meta-analysis. J Natl Cancer Inst. 2023;115(12):1483–96. pmid:37738290

4. Eamer G, Taheri A, Chen SS, Daviduck Q, Chambers T, Shi X, et al. Comprehensive geriatric assessment for older people admitted to a surgical service. Cochrane Database Syst Rev. 2018;1(1):CD012485. pmid:29385235

5. Negm AM, Kennedy CC, Thabane L, Veroniki A-A, Adachi JD, Richardson J, et al. Management of frailty: a systematic review and network meta-analysis of randomized controlled trials. J Am Med Dir Assoc. 2019;20(10):1190–8. pmid:31564464

6. Ellis G, Gardner M, Tsiachristas A, Langhorne P, Burke O, Harwood RH, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2017;9(9):CD006211. pmid:28898390

7. The World Health Organization. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization; 2003. Available from: https://iris.who.int/handle/10665/42682

8. Aminzadeh F. Adherence to recommendations of community-based comprehensive geriatric assessment programmes. Age Ageing. 2000;29(5):401–7. pmid:11108411

9. Colquhoun HL, Levac D, O’Brien KK, Straus S, Tricco AC, Perrier L. Scoping reviews: time for clarity in definition, methods, and reporting. J Clin Epidemiol. 2014;67(12):1291–4.

10. Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(1):143. pmid:30453902

11. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.

12. Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69. pmid:20854677

13. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73. pmid:30178033

14. Lely J, Morris HC, Sasson N, Camarillo ND, Livinski AA, Butera G, et al. How to write a scoping review protocol: guidance and template 2023. Available from: osf.io/ym65x

15. McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS peer review of electronic search strategies: 2015 guideline statement. J Clin Epidemiol. 2016;75:40–6.

16. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687. pmid:24609605

17. Hong QN, Gonzalez-Reyes A, Pluye P. Improving the usefulness of a tool for appraising the quality of qualitative, quantitative and mixed methods studies, the Mixed Methods Appraisal Tool (MMAT). J Eval Clin Pract. 2018;24(3):459–67. pmid:29464873

18. Hong QN, Pluye P, Fàbregues S, Bartlett G, Boardman F, Cargo M, et al. Improving the content validity of the mixed methods appraisal tool: a modified e-Delphi study. J Clin Epidemiol. 2019;111:49–59.e1.

19. Chesney TR, Daza JF, Wong CL. Geriatric assessment and treatment decision-making in surgical oncology. Curr Opin Support Palliat Care. 2023;17(1):22–30. pmid:36695865