"Hospitalization of older persons is accompanied by a disproportionate risk of poor outcomes and adverse events, such as functional decline, delirium, and falls," said presenting author Heidi Wald, MD, MSPH, a geriatrician and hospitalist at the University of Colorado Hospital and assistant professor of medicine at the University of Colorado Denver School of Medicine, both in Aurora. "Hospitalists may be the answer to some of these problems."
The study found improved processes of care with the use of a modified acute care for elders (ACE) service, which Dr. Wald called a hybrid of a general medical service and an inpatient geriatrics unit. Unlike a standard ACE unit, which is exclusively staffed by geriatric specialists, she told Medscape Internal Medicine, their service was staffed by hospitalist attendings with an interest in geriatric medicine. All patients were older than 70 years (mean age, 81 years) and were on a single medical inpatient unit when possible. Each patient received a standardized geriatric assessment.
Dr. Wald and colleagues compared processes and outcomes of care for patients (excluding transferred patients) who were assigned to either the ACE service (n = 122) or usual care (on a general internal medicine floor; n = 95) for a period of nearly 6 months between November 1, 2007, and April 15, 2008. The ACE service began at their hospital July 1, 2007, and used existing staff, although it required restructuring of the residency program. For care processes, the researchers studied recognition of abnormal functional status, cognitive function, and delirium; use of physical restraints; use of sleep aids; and documentation of code status. They studied the following outcomes of care: falls, hospital charges, length of stay, and 30-day readmission rate.
The 2 groups were similar in age, sex, diagnosis at admission, and severity of illness (case mix index), the abstract showed. However, results differed for several processes of care.
"We nearly doubled the recognition of abnormal functional status [of patients] on the ACE service vs usual care," Dr. Wald told the audience.
That difference (65% for ACE vs 32% for usual care) was statistically significant (P < .0001), according to the abstract. Patients in the ACE group also had significantly greater documentation and treatment of abnormal cognitive status (57% vs 36%, respectively; P < .01), including delirium (28% vs 15%, respectively; P < .05).
There were no statistically significant differences between groups for the other care processes studied (physical restraints, sleep aids, and code status) or for any of the outcomes of care, including length of stay. Patients on the ACE service had a slightly higher rate of readmission within 30 days (12% vs 10%; not significant), but the authors have not yet studied why, Dr. Wald said.
A study limitation, according to Dr. Wald, is that some of the measures examined are sensitive to the quality of nursing care rendered in addition to physician care. The ACE service has a dedicated nurse.
"It's clearly impractical to expect that all hospitalists would focus their care to vulnerable elders to this degree," Dr. Wald told Medscape Internal Medicine. "But we are continuing our ACE unit. Nursing staff loved this model, and patient satisfaction was quite high."
However, despite their popularity with patients and staff, ACE units have not been universally accepted, said the session comoderator, Margaret Fang, MD, in an interview with Medscape Internal Medicine. Dr. Fang, assistant professor of medicine at the University of California San Francisco (UCSF) School of Medicine and a hospitalist at the UCSF Medical Center in San Francisco, said the reason for slow acceptance is probably logistical issues, such as the need to consolidate patients onto a single floor staffed by geriatrics-trained care providers.
"But as long as the ACE model of care is cost-neutral [as this study shows], it is an alternative," she said.
Dr. Fang stressed, however, that this study does not show improved care but rather improved processes of care. "I think it will be important for Dr. Wald and her colleagues to prove that this type of unit actually improves care," she said.
She would like to see the effects of this care model on patient satisfaction and, if a larger patient population is studied, mortality, as well as additional process-oriented measures, such as accuracy of medication reconciliation.
Dr. Wald said the authors did not include data on patient satisfaction because they did not study it on the usual-care service.
Any hospital considering starting this model of care, she added, needs to get "buy-in" from multiple specialties and have interdisciplinary rounds, so as not to add extra time for staff meetings.
Source : http://www.medscape.com/viewarticle/702962?src=mpnews&spon=34&uac=133298AG
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