Table 2.
ACE unit studies and key findings *.
| Study (Setting) | Design | Patient Population (Mean Age of ACE Cohort) | ACE vs. UC Attending Physicians (Sample Sizes) | Primary Outcome Measured (ACE vs. UC) | Secondary Outcome(s) Measured (ACE vs. UC) | Study and/or Intervention Limitations | Study Strengths and/or Intervention Innovations |
|---|---|---|---|---|---|---|---|
| Landefeld et al., 1995 [4] (university hospital, USA) | RCT | General medical patients aged ≥ 70 years (80.2) | Internists on ACE (327) and UC (324) units | Significantly improved ADL performance from baseline (p = 0.05) and admission (p = 0.009) to discharge | Significantly reduced PACF placement (14% vs. 22 %, p = 0.01) Significantly improved overall health status (p < 0.001) at discharge No difference in hospital charges |
Utilized charges for cost analysis | Randomized Improved outcomes in subgroup and multivariate analyses |
| Covinsky et al., 1997 [7] (university hospital, USA) | RCT; Cost analysis from Landefeld et al., study | General medical patients aged ≥ 70 years (80.7) | Internists on ACE (326) and UC (324) units | No significant reduction in total costs per case ($6608 vs. $7240, p = 0.93) | No significant reduction in LOS (7.5 vs. 8.4 days, p = 0.449) Significantly reduced 90-day PACF use (24.1% vs. 32.3%, p = 0.034) |
Total costs includes indirect costs Lacked power to determine significance in cost difference |
Randomized Included ACE start-up costs, likely under-estimating long-term cost savings |
| Stewart et al., 1999 [8] (community teaching hospital, USA) |
Prospective observational | General medical or surgical patients aged ≥ 75 years (86) |
Internist or Surgeon on ACE (34) and UC (27) units | No significant difference in LOS (6.0 vs. 7.1 days, p = 0.06) | Significantly reduced charges ($6,223 vs. $10,042, p < 0.01) | Non-randomized Multiple significantly different baseline characteristics between cohorts and results unadjusted Utilized charges for cost analysis |
ACE care for medical and surgical patients |
| Counsell et al., 2000 [9] (community teaching hospital, USA) | RCT | Community-dwelling general medical patients with LOS ≥ 2 days aged ≥ 70 years (80) | Internist or Family Practice attending on ACE (767) and UC (764) units | No significant difference in ADL performance at discharge Significant reduction in composite outcome (ADL decline or PACF placement; 34% vs. 40%, p = 0.027) |
Significant increased use of nursing care plans (79% vs. 50%; p = 0.001), SW consults (50% vs. 43%, p = 0.012), and PT consults (42% vs. 36%, p = 0.027) Significant reduction in restraint use (2% vs. 6%; p = 0.001) Improved patient, caregiver, and provider satisfaction |
ADL outcome may have been influenced by healthier patient population and shorter LOS than Landefeld et al., RCT | Randomized Large sample size Studied ACE in patients not on a teaching service |
| Asplund et al., 2000 [10] (university hospital, Sweden) | RCT | General medical patients aged ≥ 70 years (80.9) | Internist initially followed by Geriatrician on ACE (190) vs. Internist on UC (223) units | No significant difference in poor global outcome measure α 3 months post-discharge (RR 1.06; 95% CI 0.84–1.34) | Significantly reduced LOS (5.9 vs. 7.3 days, p = 0.002) No difference in readmissions or healthcare utilization at 3 months No significant difference in hospital mortality (4% vs. 3%) |
Per-protocol analysis performed since majority of ineligible patients were due to inappropriate randomization processes | Randomized Evaluated function and well-being post-discharge |
| Salvedt et al., 2002 [11] (university hospital, Norway) | RCT | General medical patients meeting frailty criteria aged ≥ 75 years (81.8) | Geriatrician on ACE (127) vs. Internist or Medical Subspecialists on UC (127) units | Significantly reduced mortality at 3 (12% vs. 27%, p = 0.004) and 6 months (16% vs. 29%, p = 0.02) post-discharge | Significantly increased LOS (15 vs. 7 days, p < 0.001) Significantly more ACE patients with dementia, depression, and delirium diagnoses documented (38% vs. 7%, p < 0.001) |
Non-USA based study may have influenced LOS Some ACE patients were transferred from other units |
Randomized Targeted frail patients First to evaluated mortality as a primary outcome |
| Naglie et al., 2002 [12] (university hospital, Canada) | RCT | Patients with surgical hip fracture repair aged ≥ 70 years (83.8) | Geriatrician directed medical care on Ortho-ACE (141) vs. Internist directed medical care on Ortho-UC (138) units | No significant difference in composite outcome (% patients alive with no decline from baseline in ambulation, transfers, or place of residence 6 months post-surgery; adjusted OR 1.1, 95% CI 0.6–2.1) | Significant increase in % patients with composite outcome (alive with no decline from baseline in ambulation, transfers, or place of residence at 6 months) in analysis of cognitively impaired patients (47% vs. 24%, p = 0.03) Significantly increased LOS (29.2 vs. 20.9 days, p < 0.001) |
Non-USA based study may have influenced LOS Did not evaluate in-hospital outcomes |
Randomized design Extension of ACE to orthopedic surgery patients Twice weekly ACE rounds |
| Allen et al., 2003 [13] (community teaching hospital, USA) |
Pre/post comparison | Acute stroke patients pre/post launch of ACE-like stroke unit; no age criteria reported (72) | Neurologist 1-year pre (622) vs. 1-year post (544) stroke unit utilizing ACE model | Significantly reduced LOS (3.8 vs. 4.6 days, p < 0.0001) | Significantly more patients discharged home (62% vs. 50%, p < 0.0001) Significantly increased proportion of patients without a readmission at 1-year (41% vs. 18%, p < 0.0001) Significantly reduced health system Medicare stroke-specific and risk-adjusted inpatient mortality (11.4% vs. 8.4%, p = 0.02) No significant difference in all-cause mortality (7% vs. 16%; p = 0.11) |
Non-randomized Data from administrative database |
ACE team model and processes used to develop an acute stroke unit |
| Jayadevappa et al., 2006 [14] (university hospital, USA) | Retrospective case-control | General medical patients admitted for CHF, UTI, or pneumonia aged ≥ 65 years (79.6) |
Internist or Geriatrician on ACE (680) vs. Internist on UC (680) units | Significantly reduced LOS (4.9 vs. 5.9, p = 0.01) Significantly reduced mean costs ($13,586 vs. $15,039, p = 0.012) |
Reduced annual readmissions after controlling for age, race, comorbidities, and number of prior admissions | Non-randomized Data from administrative database Costs estimated from a cost-to-charge ratio |
Adjusted for prior admissions in analyzing readmission rate |
| Zelada et al., 2009 [15] (military teaching hospital, Peru) |
Prospective observational | General medical patients aged ≥ 65 years (79.6) |
Geriatrician on ACE (68) vs. Internist on UC (75) units | Significantly reduced ADL decline during hospitalization (19% vs. 40%, p = 0.013) |
Increased OR for ADL decline in UC patients (4.24; 95% CI 1.50–11.9) Reduced LOS on ACE (7.5 vs. 9.92 days, p = 0.03) |
Non-randomized Multiple significantly different baseline characteristics between cohorts |
Once weekly ACE rounds |
| Malone et al., 2010 [16] (community hospital, USA) |
Pre/post comparison | General medical or urology patients aged ≥ 65 years (no mean age reported) |
Urology or Internist on medical-surgical units pre (478) vs. post (406) e-Geriatrician | Significantly reduced use of urinary catheters (26.2 vs. 20.1%, p = 0.03) Significantly increased physical therapy referrals (27.0% vs. 39.1%; p < 0.001) |
No significant difference in use of physical restraints, social service assessments, high-risk medications, LOS, or 30-day readmissions | Non-randomized No formal tracking of whether recommendations made by geriatricians are followed |
Use of EMR tool to disseminate ACE care Twice weekly e-Geriatrician in ACE rounds |
| Flood et al., 2011 [17] (university hospital, USA) | Retrospective chart review | Hematology-oncology patients with nutritional deficits aged ≥ 65 years (75.25) |
Private Oncologist or Teaching attending with residents on Oncology-ACE (103) vs. UC (82) units | Significantly increased OR for receiving a formal nutrition consult (2.1, 95% CI 1.033–4.300) and nutritional supplements ordered (2.5; 95% CI 1.221–5.319) in adjusted analysis | Significantly increased proportion of patients receiving a nutrition consult (63.1% vs. 45.1%, p = 0.011) and an order for supplements (57.3% vs. 32.9%, p = 0.001) in unadjusted analysis | Non-randomized No standardized nutritional risk screening process on units Significantly more OACE cohort with low BMI No clinical outcomes measured |
Extension of ACE model to hematology/oncology patients Evaluated role of ACE on nutritional processes of care |
| Barnes et al., 2012 [18] (university hospital, USA) | RCT (2nd RCT from same ACE unit in Landefeld et al., study) | Community-dwelling general medical patients aged ≥ 70 years (81) |
Internists on ACE (858) and UC (774) units | Significantly reduced LOS (6.7 vs. 7.3 days, p = 0.004) Significantly reduced cost per patient ($9,477 vs. $10,451, p < 0.001) |
No significant difference in ADL, IADL, or mobility performance at discharge | Gap between time study conducted (1993–1997) and publication (2012) | Randomized Large sample size |
| Ahmed, et al., 2012 [19] (university hospital, USA) | Pre/post comparison | General medical patients aged ≥ 70 years (no mean age reported) |
Geriatrician or Geriatric Consultant with Private Internist post (1096) vs. Private and Teaching Internist on UC (383) 1-year pre-ACE |
Significant reduction in LOS (5.55 vs. 7.76 days; p = 0.001) and CMI adjusted LOS (5.16 vs. 6.40; p = 0.007) year 2 vs. baseline | No significant difference in direct costs Reduced readmission rate from baseline to years 1 and 2 combined (14.04% vs. 11.95%; no statistical analysis performed) |
Non-randomized Baseline patients from multiple different units Unequal sample sizes and time periods in pre- vs. post-cohorts |
Measured CMI adjusted LOS Measured direct costs |
| Perez-Zepeda et al., 2012 [6] (community hospitals, Mexico) | Prospective matched cohort | General medical patients with ≥ 1 targeted geriatric syndrome aged ≥ 60 years (72.6) |
Geriatricians on ACE (70) vs. Internist on UC (140) units | Significantly lower adjusted OR of composite outcome (presence of ADL decline, pressure ulcer, delirium, or death; 0.27; 95% CI 0.10–0.70) | Significantly reduced OR for ADL decline (0.23; 95% CI 0.08–0.65) No significant difference in LOS (9.9 vs. 9.3 days, p = NS) No significant difference in adjusted OR for hospital mortality (1.50; 95% CI 0.31–7.18) |
Non-randomized Small sample sizes for two-year study recruitment period |
Targeted patients with existing geriatric syndromes |
| Flood et al., 2013 [20] (university hospital, USA) | Retrospective cohort | General medical patients aged ≥ 70 years (81.6) |
Hospitalists on ACE (428) and UC (390) units | Significantly reduced variable direct costs ($2109 vs. $2480, p = 0.009) | Significantly reduced 30-day readmissions (7.9% vs. 12.8%, p = 0.02) No significant difference in discharge destination (p = 0.12) including death in hospital 1.4% vs. 1.8%) |
Non-randomized Data from administrative database |
Units had same attendings Measured variable direct costs Reduced costs despite short LOS |
| Borenstein, et al., 2016 [21] (university hospital, USA) |
Cluster RCT of hospital units | General medical patients with geriatric risk factors aged ≥ 65 years (81.1) |
Internist on medical units with (792) and without (592) ACE training and workflow redesign | Observed:Expected LOS ratio < 1 with ACE intervention and >1 on UC | Significantly reduced adjusted OR of any complication (0.45, 95% CI 0.21–0.98; p = 0.043) or transfer to ICU (0.45; 95% CI 0.25–0.79; p = 0.006) Significantly increased adjusted OR of discharge to PACF (1.43, 95% CI 1.06-1.93; p = 0.021) No significant difference in adjusted OR of hospital mortality (0.69, 95% CI 0.42–1.15; p = 0.16) |
Non-randomized Amount of uptake of NICHE care protocols on control units unknown |
Large sample size Redesigned workflows of all unit personnel to include ACE care processes |
| Ekerstad et al., 2017 [22] (community hospital, Sweden) |
Prospective controlled | General medical patients with positive frailty screen aged ≥ 75 years (85.7) |
Internist, Family Practitioner, and/or Geriatricians on ACE (206) vs. Internist on UC (202) units | Significantly reduced adjusted OR of decline in HRQOL (vision, ambulation, dexterity, emotion, cognition, pain dimensions) 3 months post-discharge | Significantly reduced 30-day readmission (19% vs. 28%, p = 0.048) Reduced adjusted 3-month mortality (HR 0.55, 95% CI 0.32–0.96) No significant difference in hospital mortality (4% vs. 5%, p = 0.6) |
Reports trial is randomized but patients assigned to ACE or UC based on bed availability | Targeted older frail patients Evaluated quality of life |
| Booth et al., 2018 [23] (university hospital, USA) |
Pre/post comparison | Orthopedic surgery or medical patients aged ≥ 65 years (74.4) |
Orthopedic Surgeon or Hospitalist pre (48) vs. post (113) ACE workflow redesign | Significantly improved completion of geriatric screens for ADL (62.5% vs. 88.5%, p < 0.001) and delirium (4.2% vs. 96.5%, p < 0.001) |
Significantly increased patients mobilized bed to chair (36.4% vs. 63.5%, p < 0.05) No significant difference in patients ambulating in hallway or delirium prevalence |
Non-randomized Small and unequal sample sizes/time periods in cohorts limits ability to measure significance |
Extension of ACE to orthopedic surgery patients Extension of ACE without geriatric specialist |
RCT = randomized controlled trial; ACE = Acute Care for Elders; UC = usual care; ADL = activities of daily living; PACF = post-acute care facility; SW = social work; PT = physical therapy; RR = relative risk; LOS = length of stay; CHF = congestive heart failure; UTI = urinary tract infection; CI = confidence interval; OR = odds ratio; EMR = electronic medical record; OACE = Oncology-Acute Care for Elders; BMI = body mass index; IADL = instrumental activities of daily living; CMI = case mix index; NICHE = Nurses Improving Care for Healthsystem Elders; HRQOL = health related quality of life; HR = hazard ratio. α global poor outcome measure = death and/or severe ADL dependence and/or poor psychological well-being. * Table modified and reprinted with permission from Malone M, Capezuti E, Palmer R. (eds) Geriatrics Models of Care: Bringing “Best Practice” to an Aging America, copyright Springer Publishing International Switzerland 2015.