Observational studyBMC geriatrics2025
Hospital-community continuity of care in fragile patients before and after major surgery-an exploratory case control study.
Observational study in BMC geriatrics, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
1 citing paper in PubMed.
- Nurse-Led Interventions Targeting Clinical Correlates of Immunosenescence in Older Adults: A Scoping Review.Medicina (Kaunas, Lithuania) · 2026Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
6 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundFrailty is a multifaceted geriatric syndrome that heightens vulnerability to adverse health outcomes, especially in surgical settings. While preoperative geriatric assessments have shown promise in mitigating these risks, their translation into actionable care plans across hospital and community settings remains a challenge. The fragmentation in Israel's healthcare system further exacerbates this issue, leaving gaps in care continuity that impact recovery outcomes for frail patients. This study evaluates a structured continuity-of-care model designed to bridge hospital-community gaps by directly transferring geriatric assessment findings to primary care physicians (PCPs). The impact on functional, mental, and physical outcomes, as well as PCP engagement, was examined.
methodsA prospective observational study with a parallel-group design was conducted among 161 elective surgery patients aged 87 and older, or 70-86 with high frailty risk scores. Frailty was measured using the Assuta Frailty Score (AFS), based on the validated Multidimensional Frailty Score (MFS). Intervention group patients received a nurse-led geriatric assessment and structured transmission of results to their PCPs, while control patients self-delivered assessment findings. Outcomes were measured three months post-surgery using the Barthel Index, Lawton IADL, and SF-12.
resultsIntervention group patients exhibited a smaller decline in ADL scores (-2.10 vs. -6.03, p = 0.14) and improved IADL outcomes (-0.54 vs. -2.09, p = 0.13). Self-reported general health also improved more in the intervention group (+ 3.89 vs. +2.47, p = 0.15). Assessment results were systematically transferred to PCPs in the intervention group, while only 35% of control patients reported doing so. Patient-reported PCP engagement with results was low in both groups (16% vs. 11%; p = 0.298).
conclusionsA structured continuity-of-care model shows potential for improving postoperative recovery among frail patients by enhancing communication between hospitals and community care providers. However, systemic barriers, including low PCP engagement and fragmented healthcare coordination, limit its full impact. Future studies should develop and evaluate integrated care models with structured communication, emotional support, and digital tools, using robust designs such as randomized or cluster trials.
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