Hospitalist Care by Geriatricians

Care for hospitalized seniors in acute geriatric units including acute care for the elderly (ACE) units have been shown to reduce function impairment and nursing home admission and possibly mortality, length of stay (LOS), and readmission.[1, 2, 3, 4, 5, 6] These units are run by specialized multidisciplinary teams with direct responsibility for the care of seniors with acute medical illnesses and are often led by geriatricians.[1] However, it is unclear whether these benefits are also achieved by hospitalist care by geriatricians working alongside other internists in general internal medicine units[7] and hospitalist care models.[8] Questions on effectiveness are relevant given the shortage of geriatricians in most healthcare systems and the escalating numbers of seniors requiring acute care. Many of these seniors have cognitive impairment, delirium, and functional decline, and longer hospital stays.[9] Beyond care settings, it is likely that specific subgroups of seniors benefit more from care delivered by geriatricians and their multidisciplinary teams. Patient characteristics defining these subgroups constitute potential targeting criteria, and these include advanced age, functional impairment, and geriatric syndromes.[10] However, to date, supporting evidence that these subgroups accrue greater benefit from care by geriatricians is lacking.[1]

Over this backdrop, our primary study aim was to determine whether hospitalist care by geriatricians for seniors aged 80 years and older in general internal medicine units improves short‐term outcomes compared with care by other internists in the setting of a busy acute‐care hospital. The secondary aim was to determine whether subgroups with premorbid functional impairment and with acute geriatric syndromes receive greater benefit from this care. Our hypotheses were that hospitalist care by geriatricians reduces hospital mortality, 30‐day mortality or readmission, and hospital LOS compared with care by other internists, and that these improvements are greater for the 2 subgroups.

METHODS

RESULTS

Among 1944 hospital episodes with data available for analysis, 968 received care by geriatricians and 976 by other internists. Death and readmission information at 30 days postdischarge was available for all. Seniors were predominantly female. About one‐quarter of seniors were nursing home residents. Only one‐third had premorbid functional independence. They had a mean number of 3 out of 30 Elixhauser comorbid conditions. Circulatory, respiratory, and genitourinary disorders accounted for more than half of primary diagnoses. The most common acute geriatric syndrome at presentation was delirium, which occurred in 3 out of every 10 seniors. More importantly, intervention and control groups only had minor differences on baseline characteristics, including nursing home residence, which was slightly more common in the intervention group (Table 1). Missing values occurred only for the explanatory variables, living arrangement, and premorbid basic activities of daily living in 0.4% to 2.7% of included hospital episodes.

There were no significant differences in hospital mortality, 30‐day mortality or readmission, and LOS between hospital episodes with care by geriatricians and other internists for the whole group and the 2 subgroups (Table 2). However, nonsignificant reduction in hospital mortality was observed for the whole group (15.5% vs 16.9%, P=0.40), with greater magnitude for the subgroup with acute geriatric syndromes (20.2% vs 23.1%, P=0.31).

When adjusted for age, gender, premorbid functional status, comorbidity, severity of illness, acute geriatric syndromes, hospitalization in the prior 30 days, and calendar year, care by geriatricians was associated with nonsignificant trends toward lower hospital mortality, with odds ratios between 0.80 and 0.89. However, 30‐day mortality or readmission and LOS for the intervention and control groups were generally equivalent (Table 3). There are only minor differences between the odds ratios and their 95% confidence intervals for regression analyses without and with additional adjustment for DRG codes (results not shown). Thus, they do not change the study results in any significant way.

DISCUSSION

Geriatricians provide direct acute hospital care for seniors either in dedicated acute geriatric units including ACE units[14] or alongside generalists or subspecialty physicians in general internal medicine units. Through an unique opportunity to study the latter arrangement, we found that hospitalist care by geriatricians for seniors aged 80 years and older in general internal medicine units did not improve their short‐term outcomes vis‐‐vis care by other internists. These findings are in contrast to those of studies on acute geriatric units. This is the first report on the effectiveness of hospitalist care for seniors provided by geriatricians. Although not a randomized controlled trial, our study is in essence a natural experiment which does not impose any major inclusion restrictions other than age of 80 years and above. Internal validity was enhanced by intervention and control groups being similar on individual‐level characteristics, whereas external validity was boosted by an all‐comers approach to enrollment.

It is pertinent to ask why hospitalist care by geriatricians in a general internal medicine department did not benefit seniors with advanced age, many of whom have functional impairment and multimorbidity. After all, improved care and outcomes seem plausible for these seniors who appear to be more vulnerable. We propose 4 possible explanations. First, unmeasured differences between intervention and control groups could have led to unobserved confounding. However, this is less likely given the nonsystematic assignment of attending physicians to different wards and similarity of intervention and control groups on a broad range of baseline characteristics. Second, care processes in wards allocated to geriatricians may not differ very much from those in other wards. Irrespective of ward, care delivered by medical residents and other healthcare professionals were also expected to be similar. Unlike acute geriatric units where comprehensive geriatric assessment (CGA) by a multidisciplinary team is thought to be responsible for the improved outcomes,[12] the influence of geriatricians outside of these units may not necessarily achieve the same level of geriatric care.[15, 16] This is precisely the challenge encountered by geriatricians in their care of acutely ill older patients in settings other than acute geriatric units, Third, diffusion of geriatric care practices across general internal medicine wards over the past decade at our hospital may have resulted in narrowed differences in the care processes particularly relevant to seniors, such as those related to functional retraining, swallowing assessment, and discharge planning, although we do not have any specific data to confirm this. These differences may in turn not be wide enough for hospitalist care by geriatricians to influence these short‐term outcomes positively. Last, our study was not designed to measure patient‐reported outcomes such as functional status, mood, quality of life, and satisfaction, which may arguably be more responsive to geriatric intervention.

It might be noted that the average LOS for hospital episodes in this study was almost 10 days, which is longer than that typically seen in North America. There are 2 possible reasons for this. First, these are hospital episodes of very old patients, and longer LOS among survivors is expected. Second, post‐acute care was not as well developed in Singapore during the study period. Since then, the system of community hospitals has expanded, thereby allowing earlier transfer to these facilities for post‐acute care and shorter LOS at acute‐care hospitals.

There are a number of limitations of our study. First, this is an observational study where treatment assignment is not allocated. Although a randomized controlled trial may be the ideal design to evaluate treatment effects, operational and ethical considerations at a busy acute‐care hospital render this very challenging to conduct. As mentioned, nonsystematic assignment of attending physicians to different wards and lack of important baseline differences between intervention and control groups support the notion that important unmeasured differences are less likely. Second, and as alluded to, we did not measure relevant patient‐reported outcomes. Nonetheless, we argue that survival is still important to many seniors, particularly those without advanced illness, whereas readmission avoidance and shorter hospital stay matter almost universally. Third, clinical charts were unavailable for data extraction in almost 3% of hospital episodes. In addition, there were missing values in 2 explanatory variables in <3% of available clinical charts. These missing values were handled by listwise deletion in the regression analyses. Doing so carries with it the risk of introducing bias in the estimation of the treatment effect of care by geriatricians. However, given the relatively small proportions of missing charts and values, it is less likely that any bias would have changed the study conclusions. Fourth, we did not account for clustering at the physician level, which would have widened the confidence intervals for the odds ratios. However, because all treatment effects on the 3 outcomes were clearly not statistically significant, widening of confidence intervals would not have changed the results and study conclusions. Finally, this is a single institution study in a single health system. Thus, caution is necessary when attempting to extrapolate its results. On the other hand, the major strength of this study is its real‐world setting, which allows the results to be more generalizable to other hospital systems with similar organization and practice of general internal medicine.

Our findings need to be placed in the context of emerging innovative models of care for hospitalized seniors, which directly or indirectly involve geriatricians. Besides traditional ACE units, which have fixed geographical locations within a hospital, a mobile acute care of the elderly service achieved shorter LOS and reduced cost than the established ACE unit with similar mortality and readmission rates.[17] Others include a proactive geriatrics consultation model in collaboration with hospitalists.[18] Another variant of the ACE unit is the hospitalist‐run acute care for the elderly (hospitalist‐ACE) service, which improved care processes without improving clinical outcomes or increasing cost.[19] Clearly, there needs to be better collaboration between hospitalists and geriatricians to improve care of acutely ill seniors.[20] Ultimately, any form of direct geriatrician care for seniors needs to be complimented by indirect care through hospital‐wide systems such the Hospital Elder Life Program. This model of care aims to prevent cognitive and functional decline in hospitalized seniors by combining CGA with protocol‐driven interventions ranging from orientation, visitation, feeding assistance, early mobilization, and visual and hearing adaptations.[21, 22]

In conclusion, hospitalist care for seniors aged 80 years and above by geriatricians based in general internal medicine units is not more effective than care by other internists, at least where reducing short‐term mortality and readmission and LOS are concerned. This is particularly applicable to hospital systems where geriatric care elements have already been widely adopted beyond the confines of acute geriatric units. However, these findings do not by any means indicate that hospitalist care provided by geriatricians is altogether not more beneficial for these seniors than care by other internists in general internal medicine units. Rather, further research on patient‐reported outcomes can clarify more fully the geriatrician's true role in this setting.

Care for hospitalized seniors in acute geriatric units including acute care for the elderly (ACE) units have been shown to reduce function impairment and nursing home admission and possibly mortality, length of stay (LOS), and readmission.[1, 2, 3, 4, 5, 6] These units are run by specialized multidisciplinary teams with direct responsibility for the care of seniors with acute medical illnesses and are often led by geriatricians.[1] However, it is unclear whether these benefits are also achieved by hospitalist care by geriatricians working alongside other internists in general internal medicine units[7] and hospitalist care models.[8] Questions on effectiveness are relevant given the shortage of geriatricians in most healthcare systems and the escalating numbers of seniors requiring acute care. Many of these seniors have cognitive impairment, delirium, and functional decline, and longer hospital stays.[9] Beyond care settings, it is likely that specific subgroups of seniors benefit more from care delivered by geriatricians and their multidisciplinary teams. Patient characteristics defining these subgroups constitute potential targeting criteria, and these include advanced age, functional impairment, and geriatric syndromes.[10] However, to date, supporting evidence that these subgroups accrue greater benefit from care by geriatricians is lacking.[1]

Over this backdrop, our primary study aim was to determine whether hospitalist care by geriatricians for seniors aged 80 years and older in general internal medicine units improves short‐term outcomes compared with care by other internists in the setting of a busy acute‐care hospital. The secondary aim was to determine whether subgroups with premorbid functional impairment and with acute geriatric syndromes receive greater benefit from this care. Our hypotheses were that hospitalist care by geriatricians reduces hospital mortality, 30‐day mortality or readmission, and hospital LOS compared with care by other internists, and that these improvements are greater for the 2 subgroups.

METHODS

RESULTS

Among 1944 hospital episodes with data available for analysis, 968 received care by geriatricians and 976 by other internists. Death and readmission information at 30 days postdischarge was available for all. Seniors were predominantly female. About one‐quarter of seniors were nursing home residents. Only one‐third had premorbid functional independence. They had a mean number of 3 out of 30 Elixhauser comorbid conditions. Circulatory, respiratory, and genitourinary disorders accounted for more than half of primary diagnoses. The most common acute geriatric syndrome at presentation was delirium, which occurred in 3 out of every 10 seniors. More importantly, intervention and control groups only had minor differences on baseline characteristics, including nursing home residence, which was slightly more common in the intervention group (Table 1). Missing values occurred only for the explanatory variables, living arrangement, and premorbid basic activities of daily living in 0.4% to 2.7% of included hospital episodes.

There were no significant differences in hospital mortality, 30‐day mortality or readmission, and LOS between hospital episodes with care by geriatricians and other internists for the whole group and the 2 subgroups (Table 2). However, nonsignificant reduction in hospital mortality was observed for the whole group (15.5% vs 16.9%, P=0.40), with greater magnitude for the subgroup with acute geriatric syndromes (20.2% vs 23.1%, P=0.31).

When adjusted for age, gender, premorbid functional status, comorbidity, severity of illness, acute geriatric syndromes, hospitalization in the prior 30 days, and calendar year, care by geriatricians was associated with nonsignificant trends toward lower hospital mortality, with odds ratios between 0.80 and 0.89. However, 30‐day mortality or readmission and LOS for the intervention and control groups were generally equivalent (Table 3). There are only minor differences between the odds ratios and their 95% confidence intervals for regression analyses without and with additional adjustment for DRG codes (results not shown). Thus, they do not change the study results in any significant way.

DISCUSSION

Geriatricians provide direct acute hospital care for seniors either in dedicated acute geriatric units including ACE units[14] or alongside generalists or subspecialty physicians in general internal medicine units. Through an unique opportunity to study the latter arrangement, we found that hospitalist care by geriatricians for seniors aged 80 years and older in general internal medicine units did not improve their short‐term outcomes vis‐‐vis care by other internists. These findings are in contrast to those of studies on acute geriatric units. This is the first report on the effectiveness of hospitalist care for seniors provided by geriatricians. Although not a randomized controlled trial, our study is in essence a natural experiment which does not impose any major inclusion restrictions other than age of 80 years and above. Internal validity was enhanced by intervention and control groups being similar on individual‐level characteristics, whereas external validity was boosted by an all‐comers approach to enrollment.

It is pertinent to ask why hospitalist care by geriatricians in a general internal medicine department did not benefit seniors with advanced age, many of whom have functional impairment and multimorbidity. After all, improved care and outcomes seem plausible for these seniors who appear to be more vulnerable. We propose 4 possible explanations. First, unmeasured differences between intervention and control groups could have led to unobserved confounding. However, this is less likely given the nonsystematic assignment of attending physicians to different wards and similarity of intervention and control groups on a broad range of baseline characteristics. Second, care processes in wards allocated to geriatricians may not differ very much from those in other wards. Irrespective of ward, care delivered by medical residents and other healthcare professionals were also expected to be similar. Unlike acute geriatric units where comprehensive geriatric assessment (CGA) by a multidisciplinary team is thought to be responsible for the improved outcomes,[12] the influence of geriatricians outside of these units may not necessarily achieve the same level of geriatric care.[15, 16] This is precisely the challenge encountered by geriatricians in their care of acutely ill older patients in settings other than acute geriatric units, Third, diffusion of geriatric care practices across general internal medicine wards over the past decade at our hospital may have resulted in narrowed differences in the care processes particularly relevant to seniors, such as those related to functional retraining, swallowing assessment, and discharge planning, although we do not have any specific data to confirm this. These differences may in turn not be wide enough for hospitalist care by geriatricians to influence these short‐term outcomes positively. Last, our study was not designed to measure patient‐reported outcomes such as functional status, mood, quality of life, and satisfaction, which may arguably be more responsive to geriatric intervention.

It might be noted that the average LOS for hospital episodes in this study was almost 10 days, which is longer than that typically seen in North America. There are 2 possible reasons for this. First, these are hospital episodes of very old patients, and longer LOS among survivors is expected. Second, post‐acute care was not as well developed in Singapore during the study period. Since then, the system of community hospitals has expanded, thereby allowing earlier transfer to these facilities for post‐acute care and shorter LOS at acute‐care hospitals.

There are a number of limitations of our study. First, this is an observational study where treatment assignment is not allocated. Although a randomized controlled trial may be the ideal design to evaluate treatment effects, operational and ethical considerations at a busy acute‐care hospital render this very challenging to conduct. As mentioned, nonsystematic assignment of attending physicians to different wards and lack of important baseline differences between intervention and control groups support the notion that important unmeasured differences are less likely. Second, and as alluded to, we did not measure relevant patient‐reported outcomes. Nonetheless, we argue that survival is still important to many seniors, particularly those without advanced illness, whereas readmission avoidance and shorter hospital stay matter almost universally. Third, clinical charts were unavailable for data extraction in almost 3% of hospital episodes. In addition, there were missing values in 2 explanatory variables in <3% of available clinical charts. These missing values were handled by listwise deletion in the regression analyses. Doing so carries with it the risk of introducing bias in the estimation of the treatment effect of care by geriatricians. However, given the relatively small proportions of missing charts and values, it is less likely that any bias would have changed the study conclusions. Fourth, we did not account for clustering at the physician level, which would have widened the confidence intervals for the odds ratios. However, because all treatment effects on the 3 outcomes were clearly not statistically significant, widening of confidence intervals would not have changed the results and study conclusions. Finally, this is a single institution study in a single health system. Thus, caution is necessary when attempting to extrapolate its results. On the other hand, the major strength of this study is its real‐world setting, which allows the results to be more generalizable to other hospital systems with similar organization and practice of general internal medicine.

Our findings need to be placed in the context of emerging innovative models of care for hospitalized seniors, which directly or indirectly involve geriatricians. Besides traditional ACE units, which have fixed geographical locations within a hospital, a mobile acute care of the elderly service achieved shorter LOS and reduced cost than the established ACE unit with similar mortality and readmission rates.[17] Others include a proactive geriatrics consultation model in collaboration with hospitalists.[18] Another variant of the ACE unit is the hospitalist‐run acute care for the elderly (hospitalist‐ACE) service, which improved care processes without improving clinical outcomes or increasing cost.[19] Clearly, there needs to be better collaboration between hospitalists and geriatricians to improve care of acutely ill seniors.[20] Ultimately, any form of direct geriatrician care for seniors needs to be complimented by indirect care through hospital‐wide systems such the Hospital Elder Life Program. This model of care aims to prevent cognitive and functional decline in hospitalized seniors by combining CGA with protocol‐driven interventions ranging from orientation, visitation, feeding assistance, early mobilization, and visual and hearing adaptations.[21, 22]

In conclusion, hospitalist care for seniors aged 80 years and above by geriatricians based in general internal medicine units is not more effective than care by other internists, at least where reducing short‐term mortality and readmission and LOS are concerned. This is particularly applicable to hospital systems where geriatric care elements have already been widely adopted beyond the confines of acute geriatric units. However, these findings do not by any means indicate that hospitalist care provided by geriatricians is altogether not more beneficial for these seniors than care by other internists in general internal medicine units. Rather, further research on patient‐reported outcomes can clarify more fully the geriatrician's true role in this setting.

Care for hospitalized seniors in acute geriatric units including acute care for the elderly (ACE) units have been shown to reduce function impairment and nursing home admission and possibly mortality, length of stay (LOS), and readmission.[1, 2, 3, 4, 5, 6] These units are run by specialized multidisciplinary teams with direct responsibility for the care of seniors with acute medical illnesses and are often led by geriatricians.[1] However, it is unclear whether these benefits are also achieved by hospitalist care by geriatricians working alongside other internists in general internal medicine units[7] and hospitalist care models.[8] Questions on effectiveness are relevant given the shortage of geriatricians in most healthcare systems and the escalating numbers of seniors requiring acute care. Many of these seniors have cognitive impairment, delirium, and functional decline, and longer hospital stays.[9] Beyond care settings, it is likely that specific subgroups of seniors benefit more from care delivered by geriatricians and their multidisciplinary teams. Patient characteristics defining these subgroups constitute potential targeting criteria, and these include advanced age, functional impairment, and geriatric syndromes.[10] However, to date, supporting evidence that these subgroups accrue greater benefit from care by geriatricians is lacking.[1]

Over this backdrop, our primary study aim was to determine whether hospitalist care by geriatricians for seniors aged 80 years and older in general internal medicine units improves short‐term outcomes compared with care by other internists in the setting of a busy acute‐care hospital. The secondary aim was to determine whether subgroups with premorbid functional impairment and with acute geriatric syndromes receive greater benefit from this care. Our hypotheses were that hospitalist care by geriatricians reduces hospital mortality, 30‐day mortality or readmission, and hospital LOS compared with care by other internists, and that these improvements are greater for the 2 subgroups.

METHODS

RESULTS

Among 1944 hospital episodes with data available for analysis, 968 received care by geriatricians and 976 by other internists. Death and readmission information at 30 days postdischarge was available for all. Seniors were predominantly female. About one‐quarter of seniors were nursing home residents. Only one‐third had premorbid functional independence. They had a mean number of 3 out of 30 Elixhauser comorbid conditions. Circulatory, respiratory, and genitourinary disorders accounted for more than half of primary diagnoses. The most common acute geriatric syndrome at presentation was delirium, which occurred in 3 out of every 10 seniors. More importantly, intervention and control groups only had minor differences on baseline characteristics, including nursing home residence, which was slightly more common in the intervention group (Table 1). Missing values occurred only for the explanatory variables, living arrangement, and premorbid basic activities of daily living in 0.4% to 2.7% of included hospital episodes.

There were no significant differences in hospital mortality, 30‐day mortality or readmission, and LOS between hospital episodes with care by geriatricians and other internists for the whole group and the 2 subgroups (Table 2). However, nonsignificant reduction in hospital mortality was observed for the whole group (15.5% vs 16.9%, P=0.40), with greater magnitude for the subgroup with acute geriatric syndromes (20.2% vs 23.1%, P=0.31).

When adjusted for age, gender, premorbid functional status, comorbidity, severity of illness, acute geriatric syndromes, hospitalization in the prior 30 days, and calendar year, care by geriatricians was associated with nonsignificant trends toward lower hospital mortality, with odds ratios between 0.80 and 0.89. However, 30‐day mortality or readmission and LOS for the intervention and control groups were generally equivalent (Table 3). There are only minor differences between the odds ratios and their 95% confidence intervals for regression analyses without and with additional adjustment for DRG codes (results not shown). Thus, they do not change the study results in any significant way.

DISCUSSION

Geriatricians provide direct acute hospital care for seniors either in dedicated acute geriatric units including ACE units[14] or alongside generalists or subspecialty physicians in general internal medicine units. Through an unique opportunity to study the latter arrangement, we found that hospitalist care by geriatricians for seniors aged 80 years and older in general internal medicine units did not improve their short‐term outcomes vis‐‐vis care by other internists. These findings are in contrast to those of studies on acute geriatric units. This is the first report on the effectiveness of hospitalist care for seniors provided by geriatricians. Although not a randomized controlled trial, our study is in essence a natural experiment which does not impose any major inclusion restrictions other than age of 80 years and above. Internal validity was enhanced by intervention and control groups being similar on individual‐level characteristics, whereas external validity was boosted by an all‐comers approach to enrollment.

It is pertinent to ask why hospitalist care by geriatricians in a general internal medicine department did not benefit seniors with advanced age, many of whom have functional impairment and multimorbidity. After all, improved care and outcomes seem plausible for these seniors who appear to be more vulnerable. We propose 4 possible explanations. First, unmeasured differences between intervention and control groups could have led to unobserved confounding. However, this is less likely given the nonsystematic assignment of attending physicians to different wards and similarity of intervention and control groups on a broad range of baseline characteristics. Second, care processes in wards allocated to geriatricians may not differ very much from those in other wards. Irrespective of ward, care delivered by medical residents and other healthcare professionals were also expected to be similar. Unlike acute geriatric units where comprehensive geriatric assessment (CGA) by a multidisciplinary team is thought to be responsible for the improved outcomes,[12] the influence of geriatricians outside of these units may not necessarily achieve the same level of geriatric care.[15, 16] This is precisely the challenge encountered by geriatricians in their care of acutely ill older patients in settings other than acute geriatric units, Third, diffusion of geriatric care practices across general internal medicine wards over the past decade at our hospital may have resulted in narrowed differences in the care processes particularly relevant to seniors, such as those related to functional retraining, swallowing assessment, and discharge planning, although we do not have any specific data to confirm this. These differences may in turn not be wide enough for hospitalist care by geriatricians to influence these short‐term outcomes positively. Last, our study was not designed to measure patient‐reported outcomes such as functional status, mood, quality of life, and satisfaction, which may arguably be more responsive to geriatric intervention.

It might be noted that the average LOS for hospital episodes in this study was almost 10 days, which is longer than that typically seen in North America. There are 2 possible reasons for this. First, these are hospital episodes of very old patients, and longer LOS among survivors is expected. Second, post‐acute care was not as well developed in Singapore during the study period. Since then, the system of community hospitals has expanded, thereby allowing earlier transfer to these facilities for post‐acute care and shorter LOS at acute‐care hospitals.

There are a number of limitations of our study. First, this is an observational study where treatment assignment is not allocated. Although a randomized controlled trial may be the ideal design to evaluate treatment effects, operational and ethical considerations at a busy acute‐care hospital render this very challenging to conduct. As mentioned, nonsystematic assignment of attending physicians to different wards and lack of important baseline differences between intervention and control groups support the notion that important unmeasured differences are less likely. Second, and as alluded to, we did not measure relevant patient‐reported outcomes. Nonetheless, we argue that survival is still important to many seniors, particularly those without advanced illness, whereas readmission avoidance and shorter hospital stay matter almost universally. Third, clinical charts were unavailable for data extraction in almost 3% of hospital episodes. In addition, there were missing values in 2 explanatory variables in <3% of available clinical charts. These missing values were handled by listwise deletion in the regression analyses. Doing so carries with it the risk of introducing bias in the estimation of the treatment effect of care by geriatricians. However, given the relatively small proportions of missing charts and values, it is less likely that any bias would have changed the study conclusions. Fourth, we did not account for clustering at the physician level, which would have widened the confidence intervals for the odds ratios. However, because all treatment effects on the 3 outcomes were clearly not statistically significant, widening of confidence intervals would not have changed the results and study conclusions. Finally, this is a single institution study in a single health system. Thus, caution is necessary when attempting to extrapolate its results. On the other hand, the major strength of this study is its real‐world setting, which allows the results to be more generalizable to other hospital systems with similar organization and practice of general internal medicine.

Our findings need to be placed in the context of emerging innovative models of care for hospitalized seniors, which directly or indirectly involve geriatricians. Besides traditional ACE units, which have fixed geographical locations within a hospital, a mobile acute care of the elderly service achieved shorter LOS and reduced cost than the established ACE unit with similar mortality and readmission rates.[17] Others include a proactive geriatrics consultation model in collaboration with hospitalists.[18] Another variant of the ACE unit is the hospitalist‐run acute care for the elderly (hospitalist‐ACE) service, which improved care processes without improving clinical outcomes or increasing cost.[19] Clearly, there needs to be better collaboration between hospitalists and geriatricians to improve care of acutely ill seniors.[20] Ultimately, any form of direct geriatrician care for seniors needs to be complimented by indirect care through hospital‐wide systems such the Hospital Elder Life Program. This model of care aims to prevent cognitive and functional decline in hospitalized seniors by combining CGA with protocol‐driven interventions ranging from orientation, visitation, feeding assistance, early mobilization, and visual and hearing adaptations.[21, 22]

In conclusion, hospitalist care for seniors aged 80 years and above by geriatricians based in general internal medicine units is not more effective than care by other internists, at least where reducing short‐term mortality and readmission and LOS are concerned. This is particularly applicable to hospital systems where geriatric care elements have already been widely adopted beyond the confines of acute geriatric units. However, these findings do not by any means indicate that hospitalist care provided by geriatricians is altogether not more beneficial for these seniors than care by other internists in general internal medicine units. Rather, further research on patient‐reported outcomes can clarify more fully the geriatrician's true role in this setting.