Quality of Care Is Associated with Survival in Vulnerable Older Patients

  1. Takahiro Higashi, MD, PhD;
  2. Paul G. Shekelle, MD, PhD;
  3. John L. Adams, PhD;
  4. Caren J. Kamberg, MSPH;
  5. Carol P. Roth, RN, MPH;
  6. David H. Solomon, MD;
  7. David B. Reuben, MD;
  8. Lillian Chiang, MD;
  9. Catherine H. MacLean, MD, PhD;
  10. John T. Chang, MD, MPH;
  11. Roy T. Young, MD;
  12. Debra M. Saliba, MD, MPH; and
  13. Neil S. Wenger, MD, MPH
  1. From RAND Health, Santa Monica, California, and Washington, DC, and the University of California, Los Angeles, and the Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California.

    Abstract

    Background: Although assessment of the quality of medical care often relies on measures of process of care, the linkage between performance of these process measures during usual clinical care and subsequent patient outcomes is unclear.

    Objective: To examine the link between the quality of care that patients received and their survival.

    Design: Observational cohort study.

    Setting: Two managed care organizations.

    Patients: Community-dwelling high-risk patients 65 years of age or older who were continuously enrolled in the managed care organizations from 1 July 1998 to 31 July 1999.

    Measurements: Quality of care received by patients (as measured by a set of quality indicators covering 22 clinical conditions) and their survival over the following 3 years.

    Results: The 372 vulnerable older patients were eligible for a mean of 21 quality indicators (range, 8 to 54) and received, on average, 53% of the care processes prescribed in quality indicators (range, 27% to 88%). Eighty-six (23%) persons died during the 3-year follow-up. There was a graded positive relationship between quality score and 3-year survival. After adjustment for sex, health status, and health service use, quality score was not associated with mortality for the first 500 days, but a higher quality score was associated with lower mortality after 500 days (hazard ratio, 0.64 [95% CI, 0.49 to 0.84] for a 10% higher quality score).

    Limitations: The observational design limits causal inference regarding the effect of quality of care on survival.

    Conclusions: Better performance on process quality measures is strongly associated with better survival among community-dwelling vulnerable older adults.

    Article and Author Information

    • Acknowledgments: The authors thank Robert Brook, MD, ScD, for inspiration and guidance; Robin P. Hertz, PhD, senior director of outcomes research and population studies at Pfizer Inc, for providing valuable support; and Patricia Smith and Victor Gonzalez for their technical assistance.

    • Grant Support: Supported by a contract from Pfizer Inc. Dr. Higashi is supported by a St. Luke's Life Science Institute Fellowship Award. Dr. Shekelle was a Senior Research Associate of the Veterans Affairs Health Services Research & Development Service. Dr. Chiang is supported by a Bureau of Health Professionals Geriatrics Research Faculty Training Program. Drs. MacLean and Saliba are Research Associates of the Veterans Affairs Health Services Research & Development Service. Dr. Chang is supported by a National Research Service Award (PE-19001) and the University of California, Los Angeles, Specialty Training and Advanced Research (STAR) Program.

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

    • Requests for Single Reprints: Neil S. Wenger, MD, MPH, RAND, 1700 Main Street, Santa Monica, CA 90407.

    • Current Author Addresses: Dr. Higashi: Department of Epidemiology and Healthcare Research, Kyoto University, Yoshida-konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan.

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

    • Drs. Shekelle, MacLean, and Saliba: Greater Los Angeles Veterans Affairs Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA 90073.

    • Drs. Solomon, Adams, and Wenger and Ms. Roth: RAND, 1700 Main Street, M-26, Santa Monica, CA 90407-2138.

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

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

    • Drs. Reuben and Chiang: Division of Geriatrics, University of California, Los Angeles, 200 Medical Plaza, Los Angeles, CA 90095-1736.

    Responses to this article

    • In Response:
      • Takahiro Higashi and
      • Neil Wenger, Paul Shekelle
      Ann Intern Med published online October 26, 2009
    • Quality of care and vulnerability
      • Stephanie L Garrett and
      • James G. O'Brien, MD, and Toni P. Miles, MD, PhD
      Ann Intern Med published online October 26, 2009

    Summary for Patients

    • Summaries for Patients:Association of Quality of Care with Survival of Elderly Managed Care Patients Ann Intern Med August 16, 2005 143:I-33
    « Previous | Next Article »Table of Contents

    This Article

    1. Ann Intern Med August 16, 2005 vol. 143 no. 4 274-281
    1. » Abstract
    2. Figures
    3. Full Text
    4. Full Text (PDF)
      1. Summary for Patients
    6. Appendix Table

    Current Issue

    1. November 3, 2009, 151 (9)
    1. Alert me to current issues