JAMA Internal Medicine: Geriatrics/Aging Topic Collection

Evaluation of the Mobile Acute Care of the Elderly (MACE) Service Mobile Acute Care of the Elderly

Hung WW, Ross JS, Farber J, et al. — Mon, 10 Jun 2013 00:00:00 GMT

Importance

Older adults are particularly vulnerable to adverse events during hospitalization for acute medical problems. The Mobile Acute Care of the Elderly (MACE) service is a novel model of care delivered by an interdisciplinary team, designed to deliver specialized care to hospitalized older adults to improve patient outcomes.

Objective

To evaluate the impact of the MACE service when compared with general medical service (usual care).

Design

Prospective, matched cohort study.

Setting

The Mount Sinai Hospital, an urban tertiary acute care hospital.

Participants

Patients aged 75 years or older admitted because of an acute illness to either the MACE service or usual care. Patients were matched for age, diagnosis, and ability to ambulate independently.

Exposures

Admission to the MACE service when compared with admission to usual care.

Main Outcome Measures

Patient outcomes included incidence of adverse events, including falls, pressure ulcers, restraint use, and catheter-associated urinary tract infections, along with length of stay, rehospitalization within 30 days, functional status at 30 days, and patient satisfaction during care transitions, measured with the 3-item Care Transition Measure.

Results

A total of 173 matched pairs of patients were recruited. The mean (SD) age was 85.2 (5.3) and 84.7 (5.4) years in the MACE and usual-care groups, respectively. After adjustment for confounders, patients in the MACE group were less likely to experience adverse events (9.5% vs 17.0%; adjusted odds ratio, 0.11; 95% CI, 0.01-0.88; P = .04) and had shorter hospital stays (0.8 days, 95% CI, 0.7-0.9; P = .001) than patients receiving usual care. Patients in the MACE group were not less likely to have a lower rate of rehospitalization within 30 days than those in the usual-care group (odds ratio, 0.91; 95% CI, 0.39-2.10; P = .83). Functional status did not differ between the 2 groups. Care Transition Measure scores were 7.4 points (95% CI, 2.9-11.9; P = .001) higher in the MACE group.

Conclusions and Relevance

Admission to the MACE service was associated with lower rates of adverse events, shorter hospital stays, and better satisfaction. This model has the potential to improve care outcomes among hospitalized older adults.

Trial Registration

clinicaltrials.gov Identifier: NCT00927160

ACE, MACE, and GRACE: Time to Put the Pieces Together Comment on “Effects of an Acute Care for Elders Unit on Costs and 30-Day Readmissions” ACE, MACE, and GRACE

Walke LM, Tinetti ME. — Mon, 10 Jun 2013 00:00:00 GMT

Berwick et al challenged the US health care system to achieve the Triple Aim of higher-quality care for individuals, improved health of populations, and lower health care costs. Accomplishing the 3-part aim is a formidable task, perhaps for no group more so than for older adults with complex health problems who are the major users of health care. However, several innovative geriatric health care programs have had modest success.

Effects of an Acute Care for Elders Unit on Costs and 30-Day Readmissions ACE Unit Model for Care

Flood KL, MacLennan PA, McGrew D, et al. — Mon, 10 Jun 2013 00:00:00 GMT

Importance

Providing high-quality care while containing cost is essential for the economic stability of our health care system. The United States is experiencing a rapidly growing elderly population. The Acute Care for Elders (ACE) unit interdisciplinary team model of care has been shown to improve outcomes in hospitalized older adults. The University of Alabama at Birmingham ACE unit incorporates evidence-based care processes. We hypothesized that the ACE model would also reduce costs.

Objective

To examine variable direct costs from an interdisciplinary ACE compared with a multidisciplinary usual care (UC) unit.

Design

Retrospective cohort study.

Setting

Tertiary care academic medical center.

Participants

Hospitalists' patients aged 70 years or older spending the entirety of their hospitalization in either the ACE or UC unit in fiscal year 2010.

Main Outcome Measures

Using administrative data, we analyzed variable direct costs for ACE and UC patients. We also conducted a subset analysis restricted to the 25 most common diagnosis related groups (DRGs) shared by ACE and UC patients. Generalized linear regression was used to estimate cost ratios and 95% confidence intervals adjusted for age, sex, comorbidity score, and case mix index (CMI).

Results

A total of 818 hospitalists' patients met inclusion criteria: 428 from the ACE and 390 from the UC unit. For this study group (all DRGs), the mean (SD) variable direct cost per patient was $2109 ($1870) for ACE and $2480 ($2113) for UC (P = .009). Adjusted cost ratios revealed significant cost savings for patients with low (0.82; 95% CI, 0.72-0.94) or moderate (0.74; 95% CI, 0.62-0.89) CMI scores; care was cost neutral for patients with high CMI scores (1.13; 95% CI, 0.93-1.37). Significantly fewer ACE patients than UC patients were readmitted within 30 days of discharge (7.9% vs 12.8%; P = .02). Subset analysis of the 25 most common DRGs revealed a significantly reduced mean (SD) variable direct cost per patient for ACE compared with UC patients ($1693 [$1063] vs $2138 [$1431]; P < .001); cost ratios for total (0.78; 95% CI, 0.70-0.87) and daily (0.89; 95% CI, 0.85-0.94) variable direct costs remained significant after adjustment.

Conclusions and Relevance

The ACE unit team model reduces costs and 30-day readmissions. In an era when improving care processes while reducing costs is a vital objective for the Medicare program and our nation as a whole, the ACE model meets these goals.

Association Between Hypoglycemia and Dementia in a Biracial Cohort of Older Adults With Diabetes Mellitus Hypoglycemia and Dementia in Older Adults With DM

Yaffe K, Falvey CM, Hamilton N, et al. — Mon, 10 Jun 2013 00:00:00 GMT

Importance

Hypoglycemia commonly occurs in patients with diabetes mellitus (DM) and may negatively influence cognitive performance. Cognitive impairment in turn can compromise DM management and lead to hypoglycemia.

Objective

To prospectively evaluate the association between hypoglycemia and dementia in a biracial cohort of older adults with DM.

Design and Setting

Prospective population-based study.

Participants

We studied 783 older adults with DM (mean age, 74.0 years; 47.0% of black race/ethnicity; and 47.6% female) who were participating in the prospective population-based Health, Aging, and Body Composition Study beginning in 1997 and who had baseline Modified Mini-Mental State Examination scores of 80 or higher.

Main Outcome Measures

Dementia diagnosis was determined during the follow-up period from hospital records indicating an admission associated with dementia or the use of prescribed dementia medications. Hypoglycemic events were determined during the follow-up period by hospital records.

Results

During the 12-year follow-up period, 61 participants (7.8%) had a reported hypoglycemic event, and 148 (18.9%) developed dementia. Those who experienced a hypoglycemic event had a 2-fold increased risk for developing dementia compared with those who did not have a hypoglycemic event (34.4% vs 17.6%, P < .001; multivariate-adjusted hazard ratio, 2.1; 95% CI, 1.0-4.4). Similarly, older adults with DM who developed dementia had a greater risk for having a subsequent hypoglycemic event compared with participants who did not develop dementia (14.2% vs 6.3%, P < .001; multivariate-adjusted hazard ratio, 3.1; 95% CI, 1.5-6.6). Further adjustment for stroke, hypertension, myocardial infarction, and cognitive change scores produced similar results.

Conclusion and Relevance

Among older adults with DM, there seems to be a bidirectional association between hypoglycemia and dementia.

Glucose Control in Older Adults With Diabetes Mellitus—More Harm Than Good? Comment on “The Association Between Hypoglycemia and Dementia in a Biracial Cohort of Older Adults With Diabetes Mellitus” Glucose Control in Older Adults With DM

Lipska KJ, Montori VM. — Mon, 10 Jun 2013 00:00:00 GMT

Ms Andrews, your 83-year-old patient, is proud. She walks daily, watches her diet, and never misses her appointments. Her glycated hemoglobin (HbA_1c) level is 6.9%. As she readies to leave, you notice her bruised arm. It is from one of her fainting spells, she says. After asking a few more questions, you realize she has been having hypoglycemic episodes, including at least 1 last week in which she lost consciousness and needed her son's assistance. Perhaps not all is as it seems. Based on multiple performance metrics, her care has been exemplary. But has your treatment caused more harm than good?

Use of Acute Care Services Among Older Homeless Adults

Brown RT, Kiely DK, Bharel M, et al. — Mon, 10 Jun 2013 00:00:00 GMT

The median age of homeless single adults in the United States has increased from approximately 35 years in 1990 to nearly 50 years in 2010, yet little is known about health care utilization among older homeless adults. Homeless adults 50 years or older have unique medical problems, including high rates of chronic illnesses and geriatric conditions. A better understanding of the health care use by this vulnerable population would help to target strategies to improve their care. Thus, we prospectively observed a cohort of older homeless adults to describe and identify modifiable factors associated with emergency department (ED) visits and hospitalizations during a 1-year period.