We interpret the findings very differently from the way Dr. Garrett and colleagues did, although we agree with their conclusion that there is a strong argument for palliative medicine for many of the patients in the study sample. Many of the quality indicators in the ACOVE measurement set focused on pain and end-of-life care.

Dr. Garrett and colleagues state that there is a lack of association between our quality measurement and survival, yet the analyses in the article demonstrate a strong relationship. Their concern that only 1 of 9 of the most prevalent quality indicators (in Table 2) demonstrated a statistically significant relationship between receiving the care process and survival misses the point; these ancillary analyses, which are statistically underpowered and unadjusted, were presented only to provide insight into potential mechanisms of the relationship between process and outcome. We focused on the direction of the point estimates by showing that the relative risk for death for those who passed the quality indicators was less than 1.0 in 8 of the 9 quality indicators.

Dr. Garrett and colleagues expressed concerns about our use of the VES-13 to select community-dwelling vulnerable older persons, and they were interested in the age distribution within our sample. Furthermore, they were concerned about the relationship between age and survival in our cohort. There were 135 persons who were 85 years of age or older, 79 of whom had VES-13 scores of 5 or less. The VES-13, which takes age into consideration, was a strong predictor of survival, as expected. We share Dr. Garrett and colleagues' excitement about our findings and their commitment to quality care for older patients.