A controlled trial of inpatient and outpatient geriatric evaluation and management. Do acute care for elders units increase hospital costs? A cost analysis using the hospital perspective. Inpatient community-based geriatric assessment reduces subsequent mortality. A randomized trial of intra-hospital relocation of geriatric patients in a tertiary-care teaching hospital. Reducing hospital costs for the geriatric patient admitted from the emergency department: a randomized trial. A negative trial of inpatient geriatric consultation. Lessons learned and recommendations for future research. Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of Acute Care for Elders (ACE) in a community hospital. A randomised study of outcomes in a defined group of acutely ill elderly patients managed in a geriatric assessment unit or a general medical unit. The Senior Care Study. A controlled trial of a consultative/unit-based geriatric assessment program in acute care. A randomized trial of comprehensive geriatric assessment in the care of hospitalized patients. Effectiveness of an inpatient geriatric service in a university hospital. An innovative approach to geriatric acute care delivery: the Choate-Symmes experience. A randomized, controlled clinical trial of a geriatric consultation team. Compliance with recommendations. Randomised trial of in-hospital geriatric intervention: impact on function and morale.
Over the past 20 years, both inpatient units and outpatient clinics have developed programs for geriatric evaluation and management. However, the effects of these interventions on survival and functional status remain uncertain.
                We conducted a randomized trial involving frail patients 65 years of age or older who were hospitalized at 11 Veterans Affairs medical centers. After their condition had been stabilized, patients were randomly assigned, according to a two-by-two factorial design, to receive either care in an inpatient geriatric unit or usual inpatient care, followed by either care at an outpatient geriatric clinic or usual outpatient care. The interventions involved teams that provided geriatric assessment and management according to Veterans Affairs standards and published guidelines. The primary outcomes were survival and health-related quality of life, measured with the use of the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36), one year after randomization. Secondary outcomes were the ability to perform activities of daily living, physical performance, utilization of health services, and costs.
                A total of 1388 patients were enrolled and followed. Neither the inpatient nor the outpatient intervention had a significant effect on mortality (21 percent at one year overall), nor were there any synergistic effects between the two interventions. At discharge, patients assigned to the inpatient geriatric units had significantly greater improvements in the scores for four of the eight SF-36 subscales, activities of daily living, and physical performance than did those assigned to usual inpatient care. At one year, patients assigned to the outpatient geriatric clinics had better scores on the SF-36 mental health subscale, even after adjustment for the score at discharge, than those assigned to usual outpatient care. Total costs at one year were similar for the intervention and usual-care groups.
                In this controlled trial, care provided in inpatient geriatric units and outpatient geriatric clinics had no significant effects on survival. There were significant reductions in functional decline with inpatient geriatric evaluation and management and improvements in mental health with outpatient geriatric evaluation and management, with no increase in costs. To compare the hospital costs of caring for medical patients on a special unit designed to help older people maintain or achieve independence in self-care activities with the costs of usual care.
                A randomized controlled study.
                A total of 650 medical patients (mean age 80 years, 67% women, 41% nonwhite) assigned randomly to either the intervention unit (n = 326) or usual care (n = 324).
                The hospital's resource-based cost of caring for patients was determined from the hospital's cost-accounting system. The cost of the intervention program was estimated and included in the intervention patients' total hospital cost.
                The development and maintenance costs of the intervention added $38.43 per bed day to the intervention patients' hospital costs. As a result, the cost per day to the hospital was slightly higher in the intervention patients than in the control patients ($876 vs $847, P = .076). However, the average length of stay was shorter for intervention patients (7.5 vs 8.4 days, P = .449). As a result, the hospital's total cost to care for intervention patients was not greater than caring for usual-care patients ($6608 in intervention patients vs $7240 in control patients, P = .926). Sensitivity analysis demonstrated that the cost of the intervention program would need to be 220% greater than estimated before intervention patients would be more expensive then control patients. There were no examined subgroups of patients in whom care on the intervention unit was significantly more expensive than care on the usual-care unit. Ninety-day nursing home use was lower in intervention than control patients (24.1% vs 32.3%, P = .034). Ninety-day readmission rates (36.7% vs 41.1%, P = .283) and caregiver strain scores (3.3 vs. 2.7, P = .280) were similar.
                Caring for patients on an intervention ward designed to improve functional outcomes in older patients was not more expensive to the hospital than caring for patients on a usual-care ward even though the intervention ward required a commitment of hospital resources. To evaluate the effect of an Inpatient Geriatric Consultation Team on patient outcome.
                Randomized controlled clinical trial.
                A non-academic-affiliated 503-bed community hospital.
                All inpatients over the age of 70 years. Sixty-two patients received multidimensional geriatric assessment, and 58 patients received no intervention.
                Team assessment, leading to formal recommendations to the attending physician.
                Data were collected on hospital length of stay, referrals to community service, discharge destination, hospital readmissions in 6 months, number of post-discharge physician visits, and change in functional status. Mortality at 6 months and at 1 year was determined for each patient.
                At 6 months, 12/58 patients (21%) had died in the control group versus 3/62 (6%) patients in the experimental group (P = 0.01). During hospitalization, the length-of-stay was 10.1 days for the control group versus 9.0 days for the experimental group (P = 0.20). The control group had significantly more readmissions (0.6 per patient vs 0.3 per patient, P = 0.02). A higher number of experimental patients, 22% (13/59), showed improvement in ADL scores compared with 7% (4/46) of control patients, P = 0.07. At one year for all randomized patients, 7/68 (10%) of experimental patients and 13/64 (20%) of control patients had died.
                Short-term mortality can be reduced in community inpatient acute hospital settings by comprehensive geriatric consultation teams. Important differences in mortality remain at 1 year of followup. Trends towards improved functional status and fewer hospital readmissions favor the intervention group. Growing numbers of aged patients are being cared for in both acute care and chronic care settings. It is often necessary to relocate elderly patients within the institution. Relocations are generally considered to increase mortality and morbidity among the elderly and to be detrimental to activities of daily living. Effects of relocation on long-term patients in an acute care institution are examined. Thirty-six (36) patients were assigned to experimental and control groups. The experimental group (n = 20) was relocated for nine weeks, while members of the control group (n = 16) remained in their original units. The two groups were evaluated for differences in mortality, morbidity, activities of daily living, and drug management. The experimental group was managed by a geriatrics team during the nine-week relocation period, while the control group remained under the supervision of a general medical surgical team. No statistically significant (P less than 0.05) differences were found with respect to mortality and morbidity, activities of daily living, or drug management. Some clinical improvements were noticed in the experimental group under the geriatrics team's supervision. The authors conclude that if careful consideration is given to the relocation of long-term patients in an acute care setting, detrimental outcomes can be avoided. To test the impact of a geriatric evaluation and management model on the costs of acute hospital management of emergently admitted older adults.
                Randomized controlled trial. Patients were followed in the acute hospital from admission through discharge. Results based on both univariate and multiple regression analyses.
                Private, nonprofit, academic medical center in a densely populated urban area.
                Adults 70 years of age and older admitted from the Emergency Department to the medicine service (non-ICU admission) who did not have an internist on staff at the admitting hospital. Of 141 randomized patients, 111 (78.7%) met eligibility criteria.
                Assignment of a geriatrician and a social worker as the primary managing team during the hospital stay.
                Length of stay, total cost of acute hospital care, cost of laboratory, pharmacy, and rehabilitation services.
                Patients in the intervention group had 2.1 fewer days of hospitalization, but this shorter length of stay was not statistically significant (P = 0.108). There were no differences in mortality or discharge disposition. In risk-adjusted, multiple regression analysis the intervention group had a statistically significant lower predicted total cost per patient than the usual care group (-$2,544, P = 0.029); assignment to the intervention group was associated with a lower predicted cost per patient for laboratory (including cardiology graphics) services (P = 0.007) and pharmacy costs (P = 0.047).
                When controlled for important predictors of expected resource use, care provided by a geriatric management team resulted in a significant reduction in the cost of hospitalization. A reduction in the cost of laboratory, cardiographic, and pharmacy services is consistent with the team's philosophy of defining the services needed based on goals related to functional outcomes. To determine the effectiveness of inpatient interdisciplinary geriatric consultation provided during hospitalization to frail, elderly subjects. SUBJECTS AND SITE: Admission cohort of 197 men admitted from 1985 through 1989, aged 65 years or more, meeting proxy criteria for frailty, living within follow-up area, without terminal illness, and without prolonged nursing home residence.
                Randomized controlled trial of inpatient geriatric consultation at a tertiary care Veterans Affairs hospital. Differences were determined between groups in the Physical Self-Maintenance Scale, Instrumental Activities of Daily Living, Mini-Mental State Examination, Morale Scale, and nursing home and health care utilization.
                No differences were seen between groups in any measure after the intervention or during 1 year of follow-up. Intervention implementation may have been incomplete due to compliance and resource availability.
                This trial is not definitive in determining whether geriatric consultation is effective or ineffective. Lessons learned from this research indicate that future studies should target frail subjects, include intervention-specific measures, and be conducted with direct control of comprehensive resources. Older persons frequently experience a decline in function following an acute medical illness and hospitalization.
                To test the hypothesis that a multicomponent intervention, called Acute Care for Elders (ACE), will improve functional outcomes and the process of care in hospitalized older patients.
                Randomized controlled trial.
                Community teaching hospital.
                A total of 1,531 community-dwelling patients, aged 70 or older, admitted for an acute medical illness between November 1994 and May 1997.
                ACE includes a specially designed environment (with, for example, carpeting and uncluttered hallways); patient-centered care, including nursing care plans for prevention of disability and rehabilitation; planning for patient discharge to home; and review of medical care to prevent iatrogenic illness.
                The main outcome was change in the number of independent activities of daily living (ADL) from 2 weeks before admission (baseline) to discharge. Secondary outcomes included resource use, implementation of orders to promote function, and patient and provider satisfaction.
                Self-reported measures of function did not differ at discharge between the intervention and usual care groups by intention-to-treat analysis. The composite outcome of ADL decline from baseline or nursing home placement was less frequent in the intervention group at discharge (34% vs 40%; P = .027) and during the year following hospitalization (P = .022). There were no significant group differences in hospital length of stay and costs, home healthcare visits, or readmissions. Nursing care plans to promote independent function were more often implemented in the intervention group (79% vs 50%; P = .001), physical therapy consults were obtained more frequently (42% vs 36%; P = .027), and restraints were applied to fewer patients (2% vs 6%; P = .001). Satisfaction with care was higher for the intervention group than the usual care group among patients, caregivers, physicians, and nurses (P < .05).
                ACE in a community hospital improved the process of care and patient and provider satisfaction without increasing hospital length of stay or costs. A lower frequency of the composite outcome ADL decline or nursing home placement may indicate potentially beneficial effects on patient outcomes. The aim of this study was to identify differences in the medical management and clinical outcome in a group of elderly patients admitted to a designated geriatric assessment unit (GAU) or to two general medical units (GMUs). A prospective randomised controlled trial was undertaken in 267 patients aged 70 years and over (mean age = 78.3 years). Following discharge from hospital, patients were followed up at three monthly intervals for a total of 12 months. At the time of discharge, no significant differences were found in inpatient management, length of stay, mortality rates, discharge rates to institutional care or utilisation of community services in patients admitted to the GAU and the GMUs. Similarly, no significant differences were found at three, six, nine, and 12 month follow up in case fatality, activities of daily living indices, mental health status, rates of institutional referral and the level of community service support in patients admitted to the GAU and the GMUs studied. These findings do not show any advantage for the unselected 70+ acutely ill elderly patient who is admitted to a designated geriatric assessment unit rather than to a general medical unit. Therefore, an admission policy to GAU, based solely on age 70+ is medically inappropriate and cost-inefficient. Evidence from other sources suggests that an age cohort of acutely admitted patients beyond 80 years may well have returned more optimistic findings for the GAU. In future, GAUs will require a more selective admission policy to maximise the benefits of their rehabilitative and interdisciplinary approach. Successful models of inpatient geriatric assessment have often involved long hospital stays, specialized interdisciplinary care, and prolonged follow-up, which are difficult to achieve within a prospective payment system. A randomized clinical trial was undertaken to evaluate the efficacy (maintenance or improvement in mental, emotional, and physical function) of using a geriatric assessment process in acute hospital care without increasing hospital charges or lengths of stay. Four hundred thirty-six patients greater than or equal to 75 years of age were randomly allocated to treatment (n = 221) or control (n = 215) conditions. Patients in the treatment group were admitted to a special unit and evaluated on admission by an interdisciplinary team, which developed a care plan. Although primary care was provided by the patient's own physician, the team followed the patients as consultants on the unit in the hospital, and by telephone for 2 months after discharge. The control group was placed on other units and received usual hospital care. The treatment and control groups were similar at study entry. At follow-up, there were no significant differences between the groups with respect to lengths of stay, hospital charges, mortality, change in physical function, or change in mental function. The treatment group changed more often in measured emotional function (chi 2 = 6.213, P = .045). This study indicates that it is feasible to implement consultative interdisciplinary team care in the acute-care hospital, but that its efficacy may be limited when applied to an unselected group of older patients. Although many studies describe benefits from the comprehensive assessment of elderly patients by an interdisciplinary team (comprehensive geriatric assessment), the most supportive evidence for the process has come from programs that rely on specialized inpatient units and long hospital stays. We examined whether an inpatient geriatric consultation service might also be beneficial in a trial involving four medical centers of a group-practice health maintenance organization (HMO).
                We conducted a randomized clinical trial with 2353 hospitalized patients 65 years of age or older in whom at least 1 of 13 screening criteria were present: stroke, immobility, impairment in any basic activity of daily living, malnutrition, incontinence, confusion or dementia, prolonged bed rest, recent falls, depression, social or family problems, an unplanned readmission to the hospital within three months of a previous hospital stay, a new fracture, and age of 80 years or older. Of the 1337 patients assigned to the experimental group, 1261 (94 percent) received a comprehensive geriatric assessment in the form of a consultation, with limited follow-up; the 1016 patients assigned to the control group received usual care. The functional and health status of the patients was measured at base line and 3 and 12 months later; survival was assessed at 12 months. Subgroups of patients who might be presumed to benefit from comprehensive assessment were also studied.
                The survival rate at 12 months was 74 percent in the experimental group and 75 percent in the control group. At base line, 3 months, and 12 months the scores of the two groups on measures of functional and health status were similar. The analysis of 16 subgroups did not identify any with either clearly improved functional status or improved survival.
                In this HMO, comprehensive geriatric assessment by a consultation team, with limited follow-up, did not improve the health or survival of hospitalized patients selected on the basis of screening criteria. To assess the effectiveness of an acute interdisciplinary inpatient geriatric service in a university hospital.
                Prospective randomized control study.
                Large urban university hospital.
                40 consecutive inpatients, randomized for inclusion on the geriatric service (study patients, n = 20) or to continue usual hospital care (control patients, n = 20) from among the geriatric consult population.
                Subjects were followed for changes in length of stay, hospital costs, diagnostic testing, pharmacy use, functional status, discharge disposition, and readmission within 30 days after hospitalization.
                Mean age of patients study 79.2 years (control 73.9 years). Sixty percent of study patients went home and 30% to nursing homes (control 20% home, 65% nursing homes) P = .03. Total length of stay mean 20.3 days study (control 32.7 days), length of stay after randomization mean 7.7 days study (control 11.2 days), mean overall hospital costs $23,906 study (control $45,189), and mean hospital costs after randomization study $4,671 (control $9,404) were not significantly different by F-tests due to wide variability. Laboratory use was reduced with mean 4.4 tests study (control 16.9) P = .01 and mean laboratory costs $263 study (control $828) P = .02. Functional ability improved (scale 1-7) with mean improvement study 0.8 (control 0.3) P = .09. Mean number of medications were lower in the study group by 30% P = .02; mean cost of medications at discharge was reduced with study $38 (control $112); and mean pharmacy charges after randomization decreased $462 study (control $1,268) P = .06. Readmission 30 days after discharge was not significantly different (study 21%, control 33%).
                An interdisciplinary acute geriatric service can be cost effective in providing care to elderly patients in a university hospital. It can improve outcomes measured by decreased laboratory and pharmacy usage, improved functional status, and discharge to a lesser level of care without increasing length of stay or early readmission after discharge. Hospitals, like those described in this study, must develop alternative models of health care delivery that allow them to respond to many challenges while providing high-quality health care to geriatric patients. In this program, 10-bed geriatric units were established in two hospitals, and patients age 65 and older were selected at random for admission to the units. Following comprehensive assessment, self-reliance was fostered using individualized interventions. Discharge planning began at admission. A multidisciplinary approach with regular team conferences including families was also used. Results of this approach suggest that such intervention can reduce length of stay without affecting quality of care. This paper describes the delivery model in detail, focuses on issues related to the implementation of the intervention, and highlights the lessons learned by Choate-Symmes personnel through their demonstration of the model. As part of a prospective, randomized, controlled study of the effectiveness of a geriatric consultation team, we examined compliance by the house staff with recommendations made by the team. Recommendations were formulated for 185 patients, aged 75 years or older, who were randomized into intervention (n = 92) and control (n = 93) groups. In the control group, only 27.1% of the actions that would have been recommended by the team were implemented independently by the house staff. Problems commonly neglected included polypharmacy, sensory impairment, confusion, and depression. In the intervention group, overall compliance was 71.7%. Highest compliance occurred for recommendations addressing instability and falls (95.0%) and discharge planning (94.3%). We conclude that a geriatric consultation team contributes substantial additional input into the care of older patients. Furthermore, relatively high compliance can be achieved with recommendations made by a geriatric consultation team, thereby overcoming the first barrier to the establishment of such a service. In two previous publications, we have shown that treatment of acutely sick, frail elderly patients in a Geriatric Evaluation and Management Unit (GEMU) compared to treatment in the general Medical Wards (MW) reduced mortality and improved the chances of living at home in contrast to living in nursing homes or being dead.
                The aim of this presentation was to study the impact on function, symptoms of depression and general well-being of treatment in the GEMU as compared to treatment in MW. Methods: Acutely sick, frail patients aged >or=75 years, admitted as emergencies to the Department of Internal Medicine, were randomised either to treatment in the GEMU (n = 127) or the MW (n = 127). In the GEMU the treatment strategy emphasised comprehensive interdisciplinary assessment of all relevant disorders, prevention of complications and iatrogenic conditions, early mobilisation, rehabilitation and discharge planning. The control group received treatment as usual from the Department of Internal Medicine. After discharge neither group received specific follow-up. Activities of daily living (ADL), instrumental ADL, cognitive function, symptoms of depression and general well-being were assessed 3, 6 and 12 months after discharge from hospital.
                There was no difference in function, depression or general well-being in the GEMU as compared to the MW group. If the dead were included in the analysis at the highest ADL dependency level, there was better function in the GEMU group at 3 months (p = 0.03).
                Treatment in the GEMU had no measurable beneficial impact on function, morale or symptoms of depression. Taken the previously shown mortality reduction into consideration an additional effect on function was less likely and the overall treatment effect was considered to be positive.
Comprehensive geriatric assessment increases a patient's likelihood of being alive and in their own home at up to 12 months.