Barriers to and facilitators of comprehensive geriatric assessment in primary care in France: a qualitative study exploring physicians' and nurses' experiences.

Abstract

Comprehensive geriatric assessment (CGA) is intended to address the complex care needs of frail, older adults. The CEpiA cluster-randomized trial assessed the effectiveness of CGA in France as part of complex interventions in two arms: a CGA adapted for use in primary care was conducted by a registered nurse (RN) or a general practitioner (GP). The trial's shared decision aid for the CGA-personalized care plan (PCP) was novel in two ways: tailored to primary care and aiming to improve patient engagement. The study found no significant effect on mortality, functional independence, or quality of life but suggested a reduced risk of unplanned hospital admission with GP-led CGA. It also highlighted the need to explore the CGA's perceived utility and feasibility in routine practice. In the present qualitative study, nested within the CEpiA trial, we aimed to identify barriers to and facilitators of CGA in primary care, as perceived by healthcare professionals. We conducted a qualitative study of French primary care professionals (RNs and GPs) having participated in the CEpiA trial between March 2017 and January 2018. Nineteen semi-structured interviews (16 GPs, 3 RNs) from trial arms delivering CGA were conducted. Analysis combined grounded-theory-based, thematic analysis with an interpretative, phenomenological analysis (analytical pluralism). Participants valued the adapted CGA's relevance but reported four main barriers: time constraints, poor suitability for some patients, challenges in subsequently implementing actions, and ethical concerns. Facilitators included good uptake of the tool and flexible use, and its function as a frailty-thinking guide rather than serving solely as an assessment tool. The participants reported benefits for patients, primary care providers, and the discipline of general practice. A CGA adapted for use in primary care was perceived to be valuable, relevant, and capable of integration into routine practice. The study's results prompted five key elements for implementation and optimizing CGA use in primary care: digital feasibility, flexible framework, patient-centered communication, organizational support, and patient selection. Future work should include the development of an online CGA-PCP platform, embedding ethical precautions through transparent decision-making, involve patients in CGA design, and identify which patient profiles derive the greatest benefit. ClinicalTrials.gov NCT02664454. Registration date: 2016-01-27.