The Quality of Medical Care Provided to Vulnerable Community-Dwelling Older Patients

Context Many Americans 65 years of age and older are at risk for functional decline, yet we know little about the quality of care for geriatric conditions. Contribution This study used a 13-item survey about functional status to evaluate the care of 420 people 65 years of age and older whom the investigators identified as vulnerable to functional decline. Quality of care was highly variable from condition to condition but was generally better for general medical conditions, such as diabetes, than for geriatric conditions, such as incontinence. Implications Efforts to improve care for vulnerable elders should focus on the geriatric conditions that profoundly influence functional status. The Editors The quality of care among patients 65 years of age and older has not been extensively investigated, and most existing studies have focused on general adult medical conditions. This is surprising, considering that more than 40% of all medical expenditures are for persons 65 years of age and older (1). The most comprehensive study to date of quality of care among older patients evaluated 24 process indicators among U.S. Medicare beneficiaries in all 50 states between 1997 and 1999 (2). Care for acute myocardial infarction, heart failure, stroke, and pneumonia was evaluated by using inpatient medical records. Pneumonia, breast cancer, and diabetes indicators were evaluated by using survey and Medicare claims data. The investigators found that the percentage of patients receiving appropriate care varied widely by measure and state. Several other studies of older patients evaluated cardiovascular conditions, diabetes, or aspects of preventive care and medication use (3-10). No study, however, has assessed the quality of medical care provided for geriatric conditions that profoundly affect the lives of vulnerable older patients. Furthermore, surveys find that older persons often prioritize function and comfort over disease treatment and prolongation of life (11). Quality-of-care measurement for older patients that examines only a few conditions and only indicators aimed at prolonging life yields an incomplete assessment because it ignores other conditions and aspects of care that are of equal or even greater importance to older patients. For this reason, we developed a quality assessment system that assesses more conditions. Together, these conditions account for a majority of all of the care older patients receive (12) and include several geriatric syndromes. We used this quality assessment system to evaluate the care provided to a sample of vulnerable elders at increased risk for death or functional decline. Methods The Assessing Care of Vulnerable Elders (ACOVE) project developed and applied a quality assessment system for vulnerable older persons. The assessment system aimed to develop quality indicators (QIs) that cover the spectrum of care for these patients. Indicators were implemented by using medical record abstraction and patient interview. The ACOVE Quality-of-Care Assessment System The ACOVE investigators developed a system of QIs to cover the most important conditions vulnerable elders encounter in all care venues. This system focused on processes (care behaviors) rather than outcomes for 2 reasons. First, although most agree that outcomes should be adjusted for risk when quality is measured, there is little consensus regarding the best severity measurement system (13). Second, measurement of processes of care is thought to be a more direct assessment of quality than measurement of outcomes (14). The process measures were selected to represent the various domains of care: screening and prevention, diagnosis, treatment, and follow-up. The development of the assessment system was guided by a Policy Advisory Committee, which helped to direct the focus toward practical applications, and by a Clinical Committee, which provided clinical expertise for development and monitored the assembly of the QIs into a comprehensive system (15). The methods for selecting conditions and developing the QIs have been described in detail elsewhere (12, 16). In brief, the Clinical Committee used the criteria of prevalence, impact, effectiveness of prevention or treatment, need for quality improvement, feasibility of measurement, and geriatric niche in a formal group rating process to identify 22 target conditions for quality improvement (12). For each of the 22 conditions, we developed a set of evidence-based QIs for vulnerable elders using a combination of systematic reviews and expert judgment (16). Of 420 proposed QIs, the 2 expert panels, the Clinical Committee, and the American College of Physicians Task Force on Aging accepted 236 as valid indicators; these were assembled into the ACOVE QI set (17). The 236 QIs covered the domains of care as follows: Sixty-one (26%) focused on screening and prevention, 50 (21%) focused on diagnosis, 84 (36%) focused on treatment, and 41 (17%) focused on follow-up and continuity of care. Examples of ACOVE QIs for each condition are presented in Table 1. Table 1. Examples of Assessing Care of Vulnerable Elders Quality Indicators Patients and Data Collection Using the ACOVE QI set, we assessed care provided to seniors who were enrolled in 2 managed care organizations. These patients were defined as vulnerable on the basis of self-report or proxy report on a brief, 13-item screening survey (Vulnerable Elders-13 [VE-13] Survey [18]). Vulnerable elders, identified by this function-based survey, are community-dwelling persons 65 years of age and older who have 4 times the risk for functional decline or death over the next 2 years compared with individuals not identified as vulnerable (18). Each managed care organization, 1 in the northeastern United States and the other in the southwestern United States, had more than 20 000 elderly enrollees and contracted with a network of providers to deliver care. Eligibility criteria included continuous enrollment in the managed care organization for at least 13 months and no out-of-plan care or active treatment for malignant conditions (excluding nonmelanoma skin cancer) during this period. A random sample of 3207 community-dwelling elderly adults was drawn from eligible persons in each managed care organization by using a random-number generator. Vulnerable elders were identified by using the VE-13 Survey as part of a telephone interview. Patients who did not speak English were not eligible to participate. The RAND Institutional Review Board approved the study protocol. Medical Record Review Using administrative data, we identified all inpatient and outpatient medical care received by study participants during the 13-month period of 1 July 1998 to 31 July 1999. Medical records were requested from primary care and specialist providers (including eye care and mental health providers), acute care hospitals, skilled-nursing facilities, home health agencies, and facilities providing outpatient services (for example, physical therapy). Identifying information of patients and providers was removed from the medical records. Trained nurses with previous experience in quality assessment performed medical record abstraction. Abstractors were provided with written abstraction guidelines and real-time consultation with a senior nurse reviewer. The abstractor considered all of a patient's records when assessing whether he or she was eligible for and received the indicated care processes. In other words, information on eligibility for a QI could have been derived from 1 record (such as an outpatient note) while the care process was delivered and documented in another setting (for example, inpatient medical record). If the care process was performed in the defined time interval, care was scored as complying with the QI. The senior nurse reviewer also assessed each completed medical record abstraction. Physicians reviewed QIs that required a more detailed level of clinical assessment. Examples include whether the elements of a delirium evaluation had been completed or whether an adequate intervention was performed for hyperlipidemia. An ophthalmologist evaluated selected data elements addressing vision care. Ten percent of all records were reabstracted to evaluate reliability of the abstraction process. Exact agreement on QI eligibility and score was 95%. (For details of abstractor preparation and abstraction materials, see the Appendix.) Quality-of-Care Interview A quality-of-care interview was conducted to ask study participants (or, if participants were incapable of responding, their proxies) about aspects of their care that might not be captured in the medical record (for example, physicianpatient counseling). On the basis of conditions and medications reported during the interview, patients were asked about specific processes of care they had received. Patients were also asked about care preferences that might affect the applicability of QIs. In addition, the interview included demographic questions and functional status items. The quality-of-care interview was conducted by telephone between August and October 2000 and required, on average, 44 minutes to complete. Statistical Analysis Of the 236 QIs, we were able to evaluate 207 using chart abstraction (n = 185 [89%]) or interview (n = 22 [11%]). Interview was used to score QIs for data elements that we did not collect from the medical record. A QI was scored for a patient if he or she satisfied the IF statement of the QI and thus was eligible to receive the specified care process (Table 1). A score of 1 was awarded if the care process was carried out, and a score of 0 was assigned if it was not. For QIs that included several triggering events, a score between 0 and 1 was possible. If the medical record indicated that the patient declined the care process, the QI was considered to be passed (the care was credited in both the numerator and the denominator of the indicator score). On the other hand, if the patient had a pre