An Acute Care for Elders Quality Improvement Program for Complex, High-Cost Patients Yields Savings for the System
BACKGROUND: Acute Care for Elders (ACE) programs improve outcomes for older adults; however, little is known about whether impact varies with comorbidity severity.
OBJECTIVE: To describe differences in hospital-level outcomes between ACE and routine care across various levels of comorbidity burden.
DESIGN: Cross-sectional quality improvement study.
SETTING: A 716-bed teaching hospital.
PARTICIPANTS: Medical inpatients aged ≥70 years hospitalized between September 2014 and August 2017.
INTERVENTION: ACE care, including interprofessional rounds, geriatric syndromes screening, and care protocols, in an environment prepared for elders
MEASUREMENTS: Total cost, length of stay (LOS), and 30-day readmissions. We calculated median differences for cost and LOS between ACE and usual care and explored variations across the distribution of outcomes at the 25th, 50th, 75th and 90th percentiles. Results were also stratified across quartiles of the combined comorbidity score.
RESULTS: A total of 1,429 ACE and 10,159 non-ACE patients were included in this study. The mean age was 81 years, 57% were female, and 81% were white. ACE patients had lower costs associated with care ranging from $171 at the 25th percentile to $3,687 at the 90th percentile, as well as lower LOS ranging from 0 days at the 25th percentile to 1.9 days at the 90th percentile. After stratifying by comorbidity score, the greatest differences in outcomes were among those with higher scores. There was no difference in 30-day readmission between the groups.
CONCLUSION: The greatest reductions in cost and LOS were in patients with greater comorbidity scores. Risk stratification may help hospitals prioritize admissions to ACE units to maximize the impact of the more intensive intervention.
© 2019 Society of Hospital Medicine
In 2016, 15.2% of older Americans were hospitalized compared with 7% of the overall population and their length of stay (LOS) was 0.7 days greater.1 Geriatric hospitalizations frequently result in complications, functional decline, nursing home transfers, and increased cost.2-4 This pattern of decline has been termed “hospitalitis” or dysfunctional syndrome.5,6 Hospitals need data-driven approaches to improve outcomes for elders. The Acute Care for Elders (ACE) program, which has been in existence for roughly 25 years, is one such model. ACE features include an environment prepared for older adults, patient-centered care to prevent functional and cognitive decline, frequent medical review to prevent iatrogenic injury or new geriatric syndromes, and early discharge and rehabilitation planning to maximize the likelihood of return to the community.7 Although published data vary somewhat, ACE programs have robust evidence documenting improved safety, quality, and value.8-15 A recent meta-analysis found that ACE programs decrease LOS, costs, new nursing home discharges, falls, delirium, and functional decline.16 However, of the 13 ACE trials reported to date, only five were published in the last decade. Recent rising pressure to decrease hospitalizations and reduce LOS has shifted some care to other settings and it is unclear whether the same results would persist in today’s rapid-paced hospitals.
ACE programs require enhanced resources and restructured care processes but there is a notable lack of data to guide patient selection. Admission criteria vary among the published reports, and information on whether comorbidity burden impacts the magnitude of benefit is scarce. One ACE investigator commented, “We were not able to identify a subgroup of patients who were most likely to benefit.”17 Not all hospitalized older adults can receive ACE care, and some units have closed due to financial and logistic pressures; thus, criteria to target this scarce resource are urgently needed. Our hospital implemented an ACE program in 2014 and we have measured and internally benchmarked important quality improvement metrics. Using this data, we conducted an exploratory analysis to generate hypotheses on the differential impact across the spectrum of cost, LOS, 30-day readmissions, and variations across quartiles of comorbidity severity.
METHODS
Setting and Patients
In September 2014, our 716-bed teaching hospital in Springfield, Massachusetts launched an ACE program to improve care for older adults on a single medical unit. The program succeeded in engaging the senior leadership, and geriatrics was identified as a priority in Baystate’s 5-year strategic plan. ACE patients ≥70 years were admitted from the emergency department with inpatient status. Patients transferred from other units or with advanced dementia or nearing death were excluded. Core components of the ACE program were derived from published summaries (see supplementary material).7,16
