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

  1. Neil S. Wenger, MD, MPH;
  2. David H. Solomon, MD;
  3. Carol P. Roth, RN, MPH;
  4. Catherine H. MacLean, MD, PhD;
  5. Debra Saliba, MD;
  6. Caren J. Kamberg, MSPH;
  7. Laurence Z. Rubenstein, MD, MPH;
  8. Roy T. Young, MD;
  9. Elizabeth M. Sloss, PhD;
  10. Rachel Louie, MS;
  11. John Adams, PhD;
  12. John T. Chang, MD, MPH;
  13. Patricia J. Venus, MA;
  14. John F. Schnelle, PhD; and
  15. Paul G. Shekelle, MD, PhD
  1. From RAND Health, Santa Monica, California, and Washington, DC; University of California, Los Angeles, School of Medicine, the Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles Jewish Home for the Aging, and Borun Center for Gerontological Research, Los Angeles, California; and the Center for Health Care Policy & Evaluation, United Healthcare Corp., Minnetonka, Minnesota.

    Abstract

    Background: Many people 65 years of age and older are at risk for functional decline and death. However, the resource-intensive medical care provided to this group has received little evaluation. Previous studies have focused on general medical conditions aimed at prolonging life, not on geriatric issues important for quality of life.

    Objective: To measure the quality of medical care provided to vulnerable elders by evaluating the process of care using Assessing Care of Vulnerable Elders quality indicators (QIs).

    Design: Observational cohort study.

    Setting: Managed care organizations in the northeastern and southwestern United States.

    Patients: Vulnerable older patients identified by a brief interview from a random sample of community-dwelling adults 65 years of age or older who were enrolled in 2 managed care organizations and received care between July 1998 and July 1999.

    Measurements: Percentage of 207 QIs passed, overall and for 22 target conditions; by domain of care (prevention, diagnosis, treatment, and follow-up); and by general medical condition (for example, diabetes and heart failure) or geriatric condition (for example, falls and incontinence).

    Results: Patients were eligible for 10 711 QIs, of which 55% were passed. There was no overall difference between managed care organizations. Wide variation in adherence was found among conditions, ranging from 9% for end-of-life care to 82% for stroke care. More treatment QIs were completed (81%) compared with other domains (follow-up, 63%; diagnosis, 46%; and prevention, 43%). Adherence to QIs was lower for geriatric conditions than for general medical conditions (31% vs. 52%; P < 0.001).

    Conclusions: Care for vulnerable elders falls short of acceptable levels for a wide variety of conditions. Care for geriatric conditions is much less optimal than care for general medical conditions.

    Article and Author Information

    • Acknowledgments: The authors thank Robert Brook, MD, ScD, for initiating this project and for providing inspiration and guidance throughout the work. Robin P. Hertz, PhD, senior director of outcomes research/population studies at Pfizer Inc, provided valuable support. They also recognize the expert assistance of Dr. Ralph Levinson, who provided ophthalmologic chart review, and the technical assistance of Patricia Smith.

    • Grant Support: By a grant from Pfizer Inc to RAND.

    • Potential Financial Conflicts of Interest:Stock ownership or options (other than mutual funds): D.H. Solomon, R.T. Young, R. Louie (Pfizer Inc).

    • Requests for Single Reprints: Neil S. Wenger, MD, RAND, 1700 Main Street, M-26, Santa Monica, CA 90407-2138; e-mail, nwenger{at}mednet.ucla.edu.

    • Current Author Addresses: Drs. Wenger, Solomon, MacLean, Saliba, and Adams; Ms. Roth; and Ms. Louie: RAND, 1700 Main Street, M-26, Santa Monica, CA 90407-2138.

    • Ms. Kamberg and Dr. Sloss: RAND, 1200 South Hayes Street, Arlington, VA 22202.

    • Dr. Rubenstein: Geriatric Research Education and Clinical Center, Sepulveda Veterans Affairs Medical Center, 16111 Plummer Street, 11E, Sepulveda, CA 91343.

    • Dr. Young: Division of General Internal Medicine, University of California, Los Angeles, 200 Medical Plaza, Los Angeles, CA 90095-1736.

    • Dr. Chang: Division of General Internal Medicine, University of California, Los Angeles, 911 Broxton Plaza, Los Angeles, CA 90095-1736.

    • Ms. Venus: Center for Health Care Policy and Evaluation, 12125 Technology Drive, MN002-0260, Minneapolis, MN 55344.

    • Dr. Schnelle: University of California, Los Angeles, 7150 Tampa Avenue, Reseda, CA 91335.

    • Dr. Shekelle: Greater Los Angeles Veterans Affairs Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA 90073.

    • Author Contributions: Conception and design: N.S. Wenger, D.H. Solomon, C.P. Roth, C.H. MacLean, D. Saliba, L.Z. Rubenstein, R.T. Young, E.M. Sloss, J.T. Chang, J.F. Schnelle, P.G. Shekelle.

    • Analysis and interpretation of the data: N.S. Wenger, D.H. Solomon, C.P. Roth, C.H. MacLean, D. Saliba, L.Z. Rubenstein, R.T. Young, R. Louie, J. Adams, J.T. Chang, P.G. Shekelle.

    • Drafting of the article: N.S. Wenger, J.T. Chang.

    • Critical revision of the article for important intellectual content: N.S. Wenger, D.H. Solomon, C.H. MacLean, D. Saliba, C.J. Kamberg, L.Z. Rubenstein, E.M. Sloss, R. Louie, J.T. Chang, P.G. Shekelle.

    • Final approval of the article: N.S. Wenger, D.H. Solomon, C.P. Roth, C.H. MacLean, D. Saliba, C.J. Kamberg, L.Z. Rubenstein, E.M. Sloss, R. Louie, J.T. Chang, J.F. Schnelle, P.G. Shekelle.

    • Provision of study materials or patients: C.P. Roth, P.J. Venus.

    • Statistical expertise: J. Adams.

    • Administrative, technical, or logistic support: C.P. Roth, C.J. Kamberg, E.M. Sloss, J.T. Chang.

    • Collection and assembly of data: D.H. Solomon, C.P. Roth, C.J. Kamberg, R.T. Young, R. Louie, J.T. Chang, P.J. Venus, P.G. Shekelle.

    Summary for Patients

    • Summaries for Patients:Quality of Medical Care for Patients Older Than Age 65 Years Ann Intern Med November 4, 2003 139:I-68
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    1. Ann Intern Med November 4, 2003 vol. 139 no. 9 740-747
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