This study examines elderly and advanced elderly inpatients' perceptions of acute care service quality, prioritises opportunities for quality improvement, and assesses variation in patients' satisfaction with care. Psychometrically-validated postal questionnaires were sent to random samplings of patients discharged from the US acute care facilities in 2002 (n = 2,057,164). Quality improvement priorities among non-elderly (< 65 years), elderly (65-74 years), and advanced elderly (> 74 years) were similar but substantial variation was found comparing single items between age groups. Elderly and advanced elderly patients rated the quality of meals and rooms significantly lower than the non-elderly, and the advanced elderly rated treatment decision making involvement significantly lower than the other two age groups. The data reveals specific, actionable areas for quality improvement and a non-linear relationship between age and satisfaction. Findings question assumptions regarding older patients' evaluations of care and indicate directions for quality improvement that account for their unique needs.