Impact of Inpatient GCS on CI Patients

Under the Patient Protection and Affordable Care Act of 2010, commonly referred to as the Affordable Care Act, hospitals face up to a 3% penalty in Medicare reimbursements for patients readmitted within 30 days of initial discharge, and measures have been proposed for modifying payments to hospitals based on their performance on this metric.[1] Cognitive impairment (CI) is considered a major risk factor for poor postdischarge outcomes including mortality and hospital readmission.[2, 3] Hospitals are seeking strategies to reduce postdischarge mortality and rehospitalization among patients with and without CI.[4] Such strategies include use of transitional care coaches, patient and caregiver education, postdischarge follow‐up, and provision of geriatric consultative services (GCS) for the care of complex patients in the hospital setting.[5, 6, 7]

GCS utilize comprehensive geriatric assessments and multidisciplinary processes to recognize and modify risk factors that may lead to poor outcomes among hospitalized patients.[8, 9, 10, 11] Implementation of GCS models including Acute Care for Elders and, recently, the Mobile Acute Care of the Elderly services have shown many benefits among older patients including a reduction in the hospital length of stay and readmission rates.[12, 13] The benefits of such services among hospitalized elders suffering from CI, however, are not well established. The objective of this article was to evaluate the impact of GCS on the readmission and mortality rates of older adults with CI within 12 months of their hospitalization to an urban, public hospital. We hypothesized that GCS will reduce both 12‐month hospital readmissions and mortality rates among this vulnerable group of older adults.

METHODS

The study was approved by the Indiana University institutional review board, and informed consent for identifiable chart review was obtained from subjects or their legally authorized representatives.

Population

Four hundred fifteen hospitalized patients aged 65 years or older suffering from CI were enrolled into an original, randomized, controlled trial that evaluated the effect of a computerized decision support system on their quality and outcome of care between July 1, 2006 and May 30, 2008.[14] The computerized decision support included reminders for physicians to reduce the prescription of 18 anticholinergics, minimize physical restraints and Foley catheterization, and increase referral to the local GCS.[15] That previous trial neither showed an impact on quality of care nor health utilization among older patients, including mortality and hospital readmission rates. The current study uses the data from the clinical trial cohort to evaluate the effect of GCS on the 12‐month mortality and hospital readmission rates for hospitalized elders with CI (Figure 1).

Figure 1

RESULTS

Between July 1, 2006 and May 30, 2008, 415 CI patients were enrolled in the original trial, with 176 receiving the GCS. As shown in Table 1, the GCS and non‐GCS groups differed significantly. The GCS group was older (79.2 years old, 8.1 standard deviation [SD] vs 75.8 years old, 7.8 SD; P0.001), scored lower on the SPMSQ (4.7, 2.7 SD vs 5.5, 2.7 SD; P=0.002), had fewer chronic conditions with a lower mean Charlson Comorbidity Index Score (2.1, 1.86 SD vs 2.8, 2.6 SD; P=0.023), but a higher percentage of delirium (48.9% vs 29.3%), a lower percentage of being discharged home (37.5% vs 56.1%), and a higher mean length of stay (6.4 days, 6.4 SD vs 5.6 days, 5.9 SD; P=0.004). They also had a lower malignancy rate (6.2% vs 14.6%; P=0.007) and a lower number of hospitalizations in the previous year (0.5 admissions, 0.9 SD vs 0.7 admissions, 1.1 SD; P=0.035). No differences were observed in regard to gender, ethnicity, history of myocardial infarctions, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, diabetes, and use of anticholinergic medicines.

Table 2 describes the association of various factors with receiving GCS. Patients who were positive for delirium (odds ratio [OR]=1.65; 95% confidence interval=0.98‐2.77) and were older (OR=1.04; 95% confidence interval=1.01‐1.08) had a higher propensity to receive GCS, whereas, the presence of metastatic cancer resulted in a lower propensity (OR=0.15; 95% confidence interval=0.02‐1.16) of receiving GCS. The logistic model estimated area under the receiver operating characteristic curve was 0.707.

Table 3 provides results from the Cox models for receiving GCS on readmission and mortality outcomes adjusting for various sets of covariates and with the propensity score adjustment. Model 1 presents unadjusted hazard ratio (HR). Model 2 presents HRs adjusting for a common set of covariates that were significantly associated with at least 1 of the outcomes, whereas model 3 presents the results adjusting for all covariates. All 4 models yielded similar results. As evident from this table, propensity‐adjusted HR for 30‐day readmission was still significantly higher among patients receiving GCS (HR=1.75; 95% confidence interval=1.06‐2.88) but not at 1 year (HR=1.19; 95% confidence interval=0.89‐1.59). There was a trend for decreased mortality for the GCS group at 30 days (HR=0.35; 95% confidence interval=0.09‐1.35), but it disappeared at 1 year (HR=0.91; 95% confidence interval=0.59‐1.40). A composite outcome of readmissions and mortality did not show any difference between the GCS and no‐GCS groups.

DISCUSSION

To our knowledge, this is the first study to analyze the impact of GCS on hospital readmission and mortality rates of CI patients. Our results did not show any short‐term or long‐term benefits of GCS for CI patients. Recent studies exploring cost benefits of the GCS have found trends toward lower readmission, but none focused on patients with CI.[6, 24, 25] It is important to note that our study did not use random allocation to assigning the patient into the GCS or control group, thus raising the possibility that patients who received GCS were sicker and were medically and socially more complex than those who did not receive the consult. Moreover, GCS consultation is preferentially sought for and completed for patients with CI and functional limitations, consistent with our finding that GCS patients more often have delirium and are less‐often discharged home.

The nature of the GCS team is another important consideration. Our GCS model did not include unit cohorting of patients, an important component of other proposed GCS models.[26] A recent meta‐analysis found that the GCS models without unit cohorting of patients did not have an impact on 1‐ or 12‐month readmission rates.[27] Low adherence to consultant recommendations (less than 33%) was thought to be a reason for such results. Importance of cohorting with regard to accomplishing recommendations by primary teams, importance of unit staff expertise in geriatric principles, and impact of a unit model on teamwork has also been highlighted by another review.[28] These findings lend to the hypothesis that unit cohorting and direct order placement by the GCS team may improve outcomes among CI patients, including a reduction in readmission rates.

Although readmissions rates were not statistically different between GCS and control groups at 1‐year postdischarge, 30‐day readmission rates were higher among the GCS group. Previous research among older heart failure patients found that a comprehensive transitional care intervention at the time of hospital discharge significantly shortened the time to readmission in the intervention group (P=0.026).[29] The factors identified by the study authors included enhanced supervision by the transitional healthcare teams along with improved awareness and education among treated patients that may have facilitated early recognition of clinical deterioration.[29] A recent study with intensive outpatient care that resulted in increased admissions among chronically ill adults provided a similar conclusion.[30]

GCS patients showed a trend toward decreased mortality as did patients enrolled in previous studies evaluating GCS models in the inpatient setting, as suggested by a recent review.[27] A caveat to note is that these trends favored ward‐styled GCS services as compared to our open GCS model,[27, 28] although the factors cited in these dedicated units affecting mortality included prompt attention to early rehabilitation, delirium management, and prevention of pressure ulcers and are also frequently implemented for patients in our GCS service model and therefore may have produced similar results.

Our neutral results in regard to the readmissions need to be interpreted with caution. First, this study was conducted in a hospital that supports expert geriatric and palliative care teams, both in the inpatient and the ambulatory settings, that provide consultative services and train medicine teams and hospital nursing staff. On the outpatient side, the presence of a robust geriatrics house‐calls program and the Geriatric Resources for Assessment and Care of Elders team results in above‐average care for the control group, and thus may also impact apparent outcomes.[31, 32] Second, 30‐day readmissions represent a complex outcome. Two recent reviews of hospital‐initiated interventions have shown that evidence regarding best strategies to decrease 30‐day readmissions is unclear.[33] Neither review included studies that targeted patients with CI only. The 2 programs that reduced 30‐day readmissions were multifaceted and included personnel who provide bridging between the hospital and the outpatient setting.[34] The GCS does include a focus on postdischarge resources, but does that on a case‐by‐case basis and no formal posthospital follow‐ups are provided. Moreover, the value of 30‐day readmission rates as a marker of quality, even though used by policymakers as an indicator of hospital quality, remains controversial.[35, 36] Broadening the outcomes of interest to include patient‐centered outcomes including satisfaction with care, that have shown to impact other health outcomes, may help improve understanding the benefits of GCS in hospitals.[37] Other comprehensive transitional care models that failed to show a benefit on 30‐day readmissions in older patients still resulted in higher satisfaction among patients.[38] Unfortunately, our evaluation did not include an assessment of patient satisfaction and quality of transitions.

Since the study period, GCS at our hospital now has incorporated a more robust focus on advance care planning (ACP) and execution of Physician Orders for Scope of Treatment that were legislated in the state in July 2013. The GCS team members are expert in carrying out complex ACP discussions and also partner with the inpatient palliative care team. It is quite possible that a study of more recent outcomes will yield more positive results for the selected outcomes. Thus, for future trials that aim to study the impact of GCS in the inpatient settings, it may be advisable to include important quality markers such as implementation of ACP and patient satisfaction along with the health utilization outcomes.

CONCLUSION

Our results comparing inpatient geriatrics consultative services with usual care in hospitalized elders having cognitive impairment failed to demonstrate an impact on readmissions and mortality. A clinical lesson learned, however, is that much work is still required to reduce readmission and mortality rates in this especially vulnerable patient population.

Under the Patient Protection and Affordable Care Act of 2010, commonly referred to as the Affordable Care Act, hospitals face up to a 3% penalty in Medicare reimbursements for patients readmitted within 30 days of initial discharge, and measures have been proposed for modifying payments to hospitals based on their performance on this metric.[1] Cognitive impairment (CI) is considered a major risk factor for poor postdischarge outcomes including mortality and hospital readmission.[2, 3] Hospitals are seeking strategies to reduce postdischarge mortality and rehospitalization among patients with and without CI.[4] Such strategies include use of transitional care coaches, patient and caregiver education, postdischarge follow‐up, and provision of geriatric consultative services (GCS) for the care of complex patients in the hospital setting.[5, 6, 7]

GCS utilize comprehensive geriatric assessments and multidisciplinary processes to recognize and modify risk factors that may lead to poor outcomes among hospitalized patients.[8, 9, 10, 11] Implementation of GCS models including Acute Care for Elders and, recently, the Mobile Acute Care of the Elderly services have shown many benefits among older patients including a reduction in the hospital length of stay and readmission rates.[12, 13] The benefits of such services among hospitalized elders suffering from CI, however, are not well established. The objective of this article was to evaluate the impact of GCS on the readmission and mortality rates of older adults with CI within 12 months of their hospitalization to an urban, public hospital. We hypothesized that GCS will reduce both 12‐month hospital readmissions and mortality rates among this vulnerable group of older adults.

METHODS

The study was approved by the Indiana University institutional review board, and informed consent for identifiable chart review was obtained from subjects or their legally authorized representatives.

Population

Four hundred fifteen hospitalized patients aged 65 years or older suffering from CI were enrolled into an original, randomized, controlled trial that evaluated the effect of a computerized decision support system on their quality and outcome of care between July 1, 2006 and May 30, 2008.[14] The computerized decision support included reminders for physicians to reduce the prescription of 18 anticholinergics, minimize physical restraints and Foley catheterization, and increase referral to the local GCS.[15] That previous trial neither showed an impact on quality of care nor health utilization among older patients, including mortality and hospital readmission rates. The current study uses the data from the clinical trial cohort to evaluate the effect of GCS on the 12‐month mortality and hospital readmission rates for hospitalized elders with CI (Figure 1).

Figure 1

RESULTS

Between July 1, 2006 and May 30, 2008, 415 CI patients were enrolled in the original trial, with 176 receiving the GCS. As shown in Table 1, the GCS and non‐GCS groups differed significantly. The GCS group was older (79.2 years old, 8.1 standard deviation [SD] vs 75.8 years old, 7.8 SD; P0.001), scored lower on the SPMSQ (4.7, 2.7 SD vs 5.5, 2.7 SD; P=0.002), had fewer chronic conditions with a lower mean Charlson Comorbidity Index Score (2.1, 1.86 SD vs 2.8, 2.6 SD; P=0.023), but a higher percentage of delirium (48.9% vs 29.3%), a lower percentage of being discharged home (37.5% vs 56.1%), and a higher mean length of stay (6.4 days, 6.4 SD vs 5.6 days, 5.9 SD; P=0.004). They also had a lower malignancy rate (6.2% vs 14.6%; P=0.007) and a lower number of hospitalizations in the previous year (0.5 admissions, 0.9 SD vs 0.7 admissions, 1.1 SD; P=0.035). No differences were observed in regard to gender, ethnicity, history of myocardial infarctions, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, diabetes, and use of anticholinergic medicines.

Table 2 describes the association of various factors with receiving GCS. Patients who were positive for delirium (odds ratio [OR]=1.65; 95% confidence interval=0.98‐2.77) and were older (OR=1.04; 95% confidence interval=1.01‐1.08) had a higher propensity to receive GCS, whereas, the presence of metastatic cancer resulted in a lower propensity (OR=0.15; 95% confidence interval=0.02‐1.16) of receiving GCS. The logistic model estimated area under the receiver operating characteristic curve was 0.707.

Table 3 provides results from the Cox models for receiving GCS on readmission and mortality outcomes adjusting for various sets of covariates and with the propensity score adjustment. Model 1 presents unadjusted hazard ratio (HR). Model 2 presents HRs adjusting for a common set of covariates that were significantly associated with at least 1 of the outcomes, whereas model 3 presents the results adjusting for all covariates. All 4 models yielded similar results. As evident from this table, propensity‐adjusted HR for 30‐day readmission was still significantly higher among patients receiving GCS (HR=1.75; 95% confidence interval=1.06‐2.88) but not at 1 year (HR=1.19; 95% confidence interval=0.89‐1.59). There was a trend for decreased mortality for the GCS group at 30 days (HR=0.35; 95% confidence interval=0.09‐1.35), but it disappeared at 1 year (HR=0.91; 95% confidence interval=0.59‐1.40). A composite outcome of readmissions and mortality did not show any difference between the GCS and no‐GCS groups.

DISCUSSION

To our knowledge, this is the first study to analyze the impact of GCS on hospital readmission and mortality rates of CI patients. Our results did not show any short‐term or long‐term benefits of GCS for CI patients. Recent studies exploring cost benefits of the GCS have found trends toward lower readmission, but none focused on patients with CI.[6, 24, 25] It is important to note that our study did not use random allocation to assigning the patient into the GCS or control group, thus raising the possibility that patients who received GCS were sicker and were medically and socially more complex than those who did not receive the consult. Moreover, GCS consultation is preferentially sought for and completed for patients with CI and functional limitations, consistent with our finding that GCS patients more often have delirium and are less‐often discharged home.

The nature of the GCS team is another important consideration. Our GCS model did not include unit cohorting of patients, an important component of other proposed GCS models.[26] A recent meta‐analysis found that the GCS models without unit cohorting of patients did not have an impact on 1‐ or 12‐month readmission rates.[27] Low adherence to consultant recommendations (less than 33%) was thought to be a reason for such results. Importance of cohorting with regard to accomplishing recommendations by primary teams, importance of unit staff expertise in geriatric principles, and impact of a unit model on teamwork has also been highlighted by another review.[28] These findings lend to the hypothesis that unit cohorting and direct order placement by the GCS team may improve outcomes among CI patients, including a reduction in readmission rates.

Although readmissions rates were not statistically different between GCS and control groups at 1‐year postdischarge, 30‐day readmission rates were higher among the GCS group. Previous research among older heart failure patients found that a comprehensive transitional care intervention at the time of hospital discharge significantly shortened the time to readmission in the intervention group (P=0.026).[29] The factors identified by the study authors included enhanced supervision by the transitional healthcare teams along with improved awareness and education among treated patients that may have facilitated early recognition of clinical deterioration.[29] A recent study with intensive outpatient care that resulted in increased admissions among chronically ill adults provided a similar conclusion.[30]

GCS patients showed a trend toward decreased mortality as did patients enrolled in previous studies evaluating GCS models in the inpatient setting, as suggested by a recent review.[27] A caveat to note is that these trends favored ward‐styled GCS services as compared to our open GCS model,[27, 28] although the factors cited in these dedicated units affecting mortality included prompt attention to early rehabilitation, delirium management, and prevention of pressure ulcers and are also frequently implemented for patients in our GCS service model and therefore may have produced similar results.

Our neutral results in regard to the readmissions need to be interpreted with caution. First, this study was conducted in a hospital that supports expert geriatric and palliative care teams, both in the inpatient and the ambulatory settings, that provide consultative services and train medicine teams and hospital nursing staff. On the outpatient side, the presence of a robust geriatrics house‐calls program and the Geriatric Resources for Assessment and Care of Elders team results in above‐average care for the control group, and thus may also impact apparent outcomes.[31, 32] Second, 30‐day readmissions represent a complex outcome. Two recent reviews of hospital‐initiated interventions have shown that evidence regarding best strategies to decrease 30‐day readmissions is unclear.[33] Neither review included studies that targeted patients with CI only. The 2 programs that reduced 30‐day readmissions were multifaceted and included personnel who provide bridging between the hospital and the outpatient setting.[34] The GCS does include a focus on postdischarge resources, but does that on a case‐by‐case basis and no formal posthospital follow‐ups are provided. Moreover, the value of 30‐day readmission rates as a marker of quality, even though used by policymakers as an indicator of hospital quality, remains controversial.[35, 36] Broadening the outcomes of interest to include patient‐centered outcomes including satisfaction with care, that have shown to impact other health outcomes, may help improve understanding the benefits of GCS in hospitals.[37] Other comprehensive transitional care models that failed to show a benefit on 30‐day readmissions in older patients still resulted in higher satisfaction among patients.[38] Unfortunately, our evaluation did not include an assessment of patient satisfaction and quality of transitions.

Since the study period, GCS at our hospital now has incorporated a more robust focus on advance care planning (ACP) and execution of Physician Orders for Scope of Treatment that were legislated in the state in July 2013. The GCS team members are expert in carrying out complex ACP discussions and also partner with the inpatient palliative care team. It is quite possible that a study of more recent outcomes will yield more positive results for the selected outcomes. Thus, for future trials that aim to study the impact of GCS in the inpatient settings, it may be advisable to include important quality markers such as implementation of ACP and patient satisfaction along with the health utilization outcomes.

CONCLUSION

Our results comparing inpatient geriatrics consultative services with usual care in hospitalized elders having cognitive impairment failed to demonstrate an impact on readmissions and mortality. A clinical lesson learned, however, is that much work is still required to reduce readmission and mortality rates in this especially vulnerable patient population.

Under the Patient Protection and Affordable Care Act of 2010, commonly referred to as the Affordable Care Act, hospitals face up to a 3% penalty in Medicare reimbursements for patients readmitted within 30 days of initial discharge, and measures have been proposed for modifying payments to hospitals based on their performance on this metric.[1] Cognitive impairment (CI) is considered a major risk factor for poor postdischarge outcomes including mortality and hospital readmission.[2, 3] Hospitals are seeking strategies to reduce postdischarge mortality and rehospitalization among patients with and without CI.[4] Such strategies include use of transitional care coaches, patient and caregiver education, postdischarge follow‐up, and provision of geriatric consultative services (GCS) for the care of complex patients in the hospital setting.[5, 6, 7]

GCS utilize comprehensive geriatric assessments and multidisciplinary processes to recognize and modify risk factors that may lead to poor outcomes among hospitalized patients.[8, 9, 10, 11] Implementation of GCS models including Acute Care for Elders and, recently, the Mobile Acute Care of the Elderly services have shown many benefits among older patients including a reduction in the hospital length of stay and readmission rates.[12, 13] The benefits of such services among hospitalized elders suffering from CI, however, are not well established. The objective of this article was to evaluate the impact of GCS on the readmission and mortality rates of older adults with CI within 12 months of their hospitalization to an urban, public hospital. We hypothesized that GCS will reduce both 12‐month hospital readmissions and mortality rates among this vulnerable group of older adults.

METHODS

The study was approved by the Indiana University institutional review board, and informed consent for identifiable chart review was obtained from subjects or their legally authorized representatives.

Population

Four hundred fifteen hospitalized patients aged 65 years or older suffering from CI were enrolled into an original, randomized, controlled trial that evaluated the effect of a computerized decision support system on their quality and outcome of care between July 1, 2006 and May 30, 2008.[14] The computerized decision support included reminders for physicians to reduce the prescription of 18 anticholinergics, minimize physical restraints and Foley catheterization, and increase referral to the local GCS.[15] That previous trial neither showed an impact on quality of care nor health utilization among older patients, including mortality and hospital readmission rates. The current study uses the data from the clinical trial cohort to evaluate the effect of GCS on the 12‐month mortality and hospital readmission rates for hospitalized elders with CI (Figure 1).

Figure 1

RESULTS

Between July 1, 2006 and May 30, 2008, 415 CI patients were enrolled in the original trial, with 176 receiving the GCS. As shown in Table 1, the GCS and non‐GCS groups differed significantly. The GCS group was older (79.2 years old, 8.1 standard deviation [SD] vs 75.8 years old, 7.8 SD; P0.001), scored lower on the SPMSQ (4.7, 2.7 SD vs 5.5, 2.7 SD; P=0.002), had fewer chronic conditions with a lower mean Charlson Comorbidity Index Score (2.1, 1.86 SD vs 2.8, 2.6 SD; P=0.023), but a higher percentage of delirium (48.9% vs 29.3%), a lower percentage of being discharged home (37.5% vs 56.1%), and a higher mean length of stay (6.4 days, 6.4 SD vs 5.6 days, 5.9 SD; P=0.004). They also had a lower malignancy rate (6.2% vs 14.6%; P=0.007) and a lower number of hospitalizations in the previous year (0.5 admissions, 0.9 SD vs 0.7 admissions, 1.1 SD; P=0.035). No differences were observed in regard to gender, ethnicity, history of myocardial infarctions, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, diabetes, and use of anticholinergic medicines.

Table 2 describes the association of various factors with receiving GCS. Patients who were positive for delirium (odds ratio [OR]=1.65; 95% confidence interval=0.98‐2.77) and were older (OR=1.04; 95% confidence interval=1.01‐1.08) had a higher propensity to receive GCS, whereas, the presence of metastatic cancer resulted in a lower propensity (OR=0.15; 95% confidence interval=0.02‐1.16) of receiving GCS. The logistic model estimated area under the receiver operating characteristic curve was 0.707.

Table 3 provides results from the Cox models for receiving GCS on readmission and mortality outcomes adjusting for various sets of covariates and with the propensity score adjustment. Model 1 presents unadjusted hazard ratio (HR). Model 2 presents HRs adjusting for a common set of covariates that were significantly associated with at least 1 of the outcomes, whereas model 3 presents the results adjusting for all covariates. All 4 models yielded similar results. As evident from this table, propensity‐adjusted HR for 30‐day readmission was still significantly higher among patients receiving GCS (HR=1.75; 95% confidence interval=1.06‐2.88) but not at 1 year (HR=1.19; 95% confidence interval=0.89‐1.59). There was a trend for decreased mortality for the GCS group at 30 days (HR=0.35; 95% confidence interval=0.09‐1.35), but it disappeared at 1 year (HR=0.91; 95% confidence interval=0.59‐1.40). A composite outcome of readmissions and mortality did not show any difference between the GCS and no‐GCS groups.

DISCUSSION

To our knowledge, this is the first study to analyze the impact of GCS on hospital readmission and mortality rates of CI patients. Our results did not show any short‐term or long‐term benefits of GCS for CI patients. Recent studies exploring cost benefits of the GCS have found trends toward lower readmission, but none focused on patients with CI.[6, 24, 25] It is important to note that our study did not use random allocation to assigning the patient into the GCS or control group, thus raising the possibility that patients who received GCS were sicker and were medically and socially more complex than those who did not receive the consult. Moreover, GCS consultation is preferentially sought for and completed for patients with CI and functional limitations, consistent with our finding that GCS patients more often have delirium and are less‐often discharged home.

The nature of the GCS team is another important consideration. Our GCS model did not include unit cohorting of patients, an important component of other proposed GCS models.[26] A recent meta‐analysis found that the GCS models without unit cohorting of patients did not have an impact on 1‐ or 12‐month readmission rates.[27] Low adherence to consultant recommendations (less than 33%) was thought to be a reason for such results. Importance of cohorting with regard to accomplishing recommendations by primary teams, importance of unit staff expertise in geriatric principles, and impact of a unit model on teamwork has also been highlighted by another review.[28] These findings lend to the hypothesis that unit cohorting and direct order placement by the GCS team may improve outcomes among CI patients, including a reduction in readmission rates.

Although readmissions rates were not statistically different between GCS and control groups at 1‐year postdischarge, 30‐day readmission rates were higher among the GCS group. Previous research among older heart failure patients found that a comprehensive transitional care intervention at the time of hospital discharge significantly shortened the time to readmission in the intervention group (P=0.026).[29] The factors identified by the study authors included enhanced supervision by the transitional healthcare teams along with improved awareness and education among treated patients that may have facilitated early recognition of clinical deterioration.[29] A recent study with intensive outpatient care that resulted in increased admissions among chronically ill adults provided a similar conclusion.[30]

GCS patients showed a trend toward decreased mortality as did patients enrolled in previous studies evaluating GCS models in the inpatient setting, as suggested by a recent review.[27] A caveat to note is that these trends favored ward‐styled GCS services as compared to our open GCS model,[27, 28] although the factors cited in these dedicated units affecting mortality included prompt attention to early rehabilitation, delirium management, and prevention of pressure ulcers and are also frequently implemented for patients in our GCS service model and therefore may have produced similar results.

Our neutral results in regard to the readmissions need to be interpreted with caution. First, this study was conducted in a hospital that supports expert geriatric and palliative care teams, both in the inpatient and the ambulatory settings, that provide consultative services and train medicine teams and hospital nursing staff. On the outpatient side, the presence of a robust geriatrics house‐calls program and the Geriatric Resources for Assessment and Care of Elders team results in above‐average care for the control group, and thus may also impact apparent outcomes.[31, 32] Second, 30‐day readmissions represent a complex outcome. Two recent reviews of hospital‐initiated interventions have shown that evidence regarding best strategies to decrease 30‐day readmissions is unclear.[33] Neither review included studies that targeted patients with CI only. The 2 programs that reduced 30‐day readmissions were multifaceted and included personnel who provide bridging between the hospital and the outpatient setting.[34] The GCS does include a focus on postdischarge resources, but does that on a case‐by‐case basis and no formal posthospital follow‐ups are provided. Moreover, the value of 30‐day readmission rates as a marker of quality, even though used by policymakers as an indicator of hospital quality, remains controversial.[35, 36] Broadening the outcomes of interest to include patient‐centered outcomes including satisfaction with care, that have shown to impact other health outcomes, may help improve understanding the benefits of GCS in hospitals.[37] Other comprehensive transitional care models that failed to show a benefit on 30‐day readmissions in older patients still resulted in higher satisfaction among patients.[38] Unfortunately, our evaluation did not include an assessment of patient satisfaction and quality of transitions.

Since the study period, GCS at our hospital now has incorporated a more robust focus on advance care planning (ACP) and execution of Physician Orders for Scope of Treatment that were legislated in the state in July 2013. The GCS team members are expert in carrying out complex ACP discussions and also partner with the inpatient palliative care team. It is quite possible that a study of more recent outcomes will yield more positive results for the selected outcomes. Thus, for future trials that aim to study the impact of GCS in the inpatient settings, it may be advisable to include important quality markers such as implementation of ACP and patient satisfaction along with the health utilization outcomes.

CONCLUSION

Our results comparing inpatient geriatrics consultative services with usual care in hospitalized elders having cognitive impairment failed to demonstrate an impact on readmissions and mortality. A clinical lesson learned, however, is that much work is still required to reduce readmission and mortality rates in this especially vulnerable patient population.