Geriatricians: Maximizing Impact Now While Aiming for a Stronger Future

The global shortage of geriatricians poses a dilemma: older adults are living longer, often with multiple chronic conditions, but the workforce of specialists in geriatrics remains insufficient [1]. In this issue of the Journal of the American Geriatrics Society, Wong et al. present a modeling study that explores how best to deploy the limited number of geriatricians for maximum cost-effectiveness [2]. By testing different staffing scenarios and situating geriatricians performing comprehensive geriatric assessments (CGAs) in acute care, outpatient clinics, or rehabilitation units, they conclude that prioritizing geriatricians in acute care and rehabilitation settings may yield the greatest benefits when geriatrician coverage in all settings is not feasible.

CGA is widely regarded as central to geriatric medicine [3]. It is defined as a structured, multidimensional approach to evaluating the medical, psychosocial, and functional challenges in older adults. Conceptually, CGAs focus on addressing an older adult's overall clinical context rather than a single diagnosis. Meta-analyses indicate that CGA can raise the odds of remaining at home, reduce admissions to nursing homes, and improve functional status [4, 5]. Thus, while geriatricians may positively affect older adults in many ways, focusing on CGAs is a reasonable first-pass approach to quantify how they can improve the lives of this population.

To help guide decisions about allocating the limited number of geriatricians, Wong et al. used a two-dimensional microsimulation model to examine the costs and outcomes (as measured by Quality Adjusted Life Months or QALMs) from geriatrician-led CGA in three settings: acute care hospitals, rehabilitation units, and community clinics. Each potential deployment (i.e., geriatricians in one, two, or all three locations) is contrasted with a “usual care” scenario, where fewer older adults receive CGA. Their results were twofold. First, assigning geriatricians to acute care and rehabilitation emerged as an “undominated” strategy, meaning it lowered costs and improved health outcomes relative to several other possible configurations. Second, if additional staffing is available, extending CGA to community-based clinics remained cost-effective. In practical terms, the study suggests that, when forced to choose, placing geriatricians in hospitals and rehabilitation settings may lead to the greatest improvement in outcomes at the lowest cost. In addition, if sufficient geriatricians are available, staffing community clinics can also improve outcomes at modest cost.

Several factors can help place these results into broader context. Below, we focus on (1) the uncertainty of model results, (2) the sensitivity of the results to modeling choices such as cycle length, and (3) the cost-effectiveness of geriatricians compared to other available interventions for older adults.

Cost-effectiveness modeling relies on the accuracy of estimates of costs and likelihood of clinical outcomes. Unfortunately, there is substantial uncertainty regarding the benefits of geriatricians and CGAs in different scenarios. In acute hospital settings, CGA can increase the likelihood of returning home although it may raise costs, and the evidence for cost-effectiveness remains inconclusive [4]. While one study found no cost-effectiveness benefit for specialist geriatric interventions in frail older adults discharged from acute units [6], others have shown reductions in length of stay, lower costs, and improved outcomes when geriatricians lead or consult on care [7, 8]. In geriatric emergency departments and primary care, CGA-driven models have been associated with reduced admissions, cost savings, and better outcomes for higher-risk groups, although revisit rates can increase [9, 10]. Overall, the previous studies have reported a wide range of effectiveness (and therefore cost-effectiveness) of CGA and geriatricians, varying by care model, patient populations, and local resources. By modeling a single cost-effectiveness in each setting, the results presented by Wong et al. provide an average cost-effectiveness, without addressing the difficult but clinically important question of which patients and which care models are most likely to lead to maximum benefits. Wong et al. relied at times on unpublished effectiveness data as inputs to their models, suggesting the results should be viewed cautiously until subsequent studies validate them. Small definitional shifts in the inputs, such as the size of rehabilitative functional gains or the assumed “utility” of long-term care (LTC), could alter the intervention's cost-effectiveness from “clearly worthwhile” to “marginal” or even “unfavorable.” Thus, future research must refine the effectiveness estimates feeding these models and include robust sensitivity analyses examining a plausible range of estimates across various care settings. Doing so can quantify uncertainties and provide a more accurate understanding of the real-world cost-effectiveness of geriatricians and CGAs.

A second issue arises from the study's approach to modeling time (cycle length), particularly for hospital or rehabilitation stays. Although Wong et al. shorten their time cycles to 1 month in the acute care setting, closer than the annual cycles for outpatient contexts, typical hospitalizations can last mere days. If a full month's cost is imputed for every acute care stay, it could overinflate resource usage. Similarly, summing daily costs vs. weekly or monthly charges may yield different total costs for each hospitalization or rehabilitation stay. Even seemingly minor definitional choices like measuring length of stay in “weeks” rather than “days” can alter overall expenditures and shift conclusions about which settings or strategies are most cost-effective. In addition, the models assume that repeat CGAs generate the same benefits as the initial assessment. However, diminishing returns may arise once the most modifiable risks, such as polypharmacy or delirium, are managed on the first CGA. While subsequent CGAs may detect new syndromes, such as recurrent falls or cognitive decline, the net benefit of repeated CGAs could plausibly be smaller than the initial CGA. Exploring how repeated visits build on earlier gains (or gradually plateau) is essential, ideally using prospective data that track health trajectories over multiple CGA cycles. Such refinements would help pinpoint the optimal frequency and “dose” of CGAs and strengthen policy recommendations on how best to scale geriatric services over time.

Finally, it is instructive to compare the cost-effectiveness of geriatric services and CGAs with other interventions. A recent analysis of lecanemab for early-stage Alzheimer's disease found that gaining one QALY would cost approximately $287,000 (USD) [11]. In contrast, Wong et al. estimated that adding community-based CGA would cost about $1203 (CAD) per quality-adjusted life month (QALM) (equating to roughly $10,105 (USD) per QALY, using $1 USD = $0.7 CAD), making geriatrician-led CGA nearly 30 times more cost-effective. Put simply, for each dollar spent to improve quality of life for a year through CGA, one would need to spend almost $30 to achieve the same benefit with lecanemab. Therefore, while the current study shares important information on how to deploy the limited number of geriatricians, it is important to keep in mind that geriatricians and CGAs are potentially very cost-effective, and one of the best ways to provide the most significant benefits to older adults is to invest in increasing the number of geriatricians.

Although cost-effectiveness is a key driver of policy decisions, monetary metrics alone may underestimate the broader impact of geriatric care. Older adults often present with multifaceted social, functional, and psychosocial needs, and geriatricians do more than conduct CGAs: they devise individualized care plans that respect patients' dignity, autonomy, and preferences. Furthermore, standard QALM-based analyses cannot adequately capture the subjective benefits of goal-concordant treatment, like honoring a patient's specific values or minimizing unwanted interventions. Likewise, preventing delirium or limiting functional decline can not only enhance patients' well-being but also reduce the burden and distress of families and care partners. Given that the study's findings already favor geriatrician-led care on cost-effectiveness grounds, these additional, less easily quantified benefits suggest that the true value of geriatric expertise is likely greater than what QALY-based analyses can capture.

All authors contributed to the manuscript concept, drafting, and revision. All authors approved the final version of the manuscript for submission.

The authors declare no conflicts of interest.

This publication is linked to a related article by Wong et al. To view this article, visit https://doi.org/10.1111/jgs.19448.