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
This study has a number of limitations. First, it was conducted at a single site and may not apply to other hospitals. Second, as a quality improvement program, its design, processes, and personnel evolved over time, and, as in any multicomponent initiative, the effect of individual factors on the outcomes is unknown. Third, this is an observational study with the aim of generating hypotheses for more rigorous studies in the future and residual confounding factors may exist despite efforts to adjust for variables present in an administrative database. Thus, we were unable to completely adjust for potentially important social factors, presence of delirium, or baseline functional status.
To our knowledge, this study is the first report on the differential impact of comorbidity scores and cost distribution on ACE total cost and LOS reductions. Despite its limitations, it contributes to the existing literature by suggesting that the Gagne comorbidity score can help identify which admissions will yield the greatest value. The Gagne score could be calculated at admission using the ePrognosis risk calculator or incorporated and automated in the EMR.29 Many health systems are reluctant to designate beds for specific subpopulations since doing so decreases flexibility and complicates the admission process. A dynamic tension exists between increasing income streams now and generating future savings by supporting initiatives with upfront costs. Other successful acute care geriatrics programs, such as NICHE,30 HELP,31 MACE,32 and consultation teams, exist.33 Studies reporting the outcomes of combining ACE units with these other approaches in a “portfolio approach” will inform the design of the most efficient and impactful programs.34 Scrupulous attention to symptom control and advance care planning are key features of our program, and, given the high prevalence of advanced serious illness in hospitalized older adults, this consideration may be critical for success.
As ACE units can only care for a small fraction of hospitalized older adults, determining which patients will maximally benefit from the structured, team-based care on ACE units is crucial. We found that the greatest impact on LOS and costs occurred in the subgroup with the highest comorbidity scores and overall cost. ACE care for the most vulnerable patients appeared to yield the greatest value for the system; thus, these older adults may need to be prioritized for admission. This improvement may enhance quality and value outcomes, maximize a scarce resource, and secure results needed to sustain the “clinician-led and data-driven” ACE model in the face of changing clinical and financial landscapes.35
Acknowledgments
All those with significant contributions to this work are included as authors.
The authors express their deep appreciation to all their Baystate collaborators, particularly to Rebecca Starr, MD, the first geriatrics medical director of the program, Ms. Virginia Chipps, RN, the program’s first nurse manager, and Tasmiah Chowdhury, PharmD, the program’s first pharmacist. We are also deeply grateful to those persons who provided programmatic advice and input on model ACE programs elsewhere, including Kyle Allen, MD, Michael Malone MD, Robert Palmer MD, and, especially, Kellie Flood, MD.
Disclosures
None of the authors have any existing or potential personal or financial conflicts relevant to this paper to report.
Funding
This work was supported in part by a Geriatric Workforce Enhancement Program award (grant # U1QHP28702) from the Health Resources and Services Administration and by internal support from Baystate Health
