Am Fam Physician. 2004 Jun 15;69(12):2913-2918.
Care provided to persons older than 65 years generally includes quality medical care, but little attention is given to geriatric conditions that affect quality of life. Often older adults are concerned with function and comfort to a greater extent than they are concerned with prolonging life. Quality-of-care measurements that look only at general adult medical conditions are inadequate. Wenger and associates developed a quality assessment system that widely assesses geriatric issues among a population at risk for both increased mortality and functional decline.
The Assessing Care of Vulnerable Elders (ACOVE) quality assessment system aims at a broad set of quality indicators covering a wide range of geriatric problems. Processes, or care behaviors, related to screening and prevention, diagnosis, treatment, and follow-up are evaluated, rather than outcomes. Using committee consensus, evidence-based quality indicators were developed for 22 conditions, resulting in a total of 236 indicators. These indicators were used to assess the care of 372 vulnerable elderly patients who were enrolled in one of two managed care organizations and living in the community, who were at increased risk for functional decline and had available medical histories representing health care during the study period. Indicators were evaluated using chart information from all health care providers who saw the patients and from interviews with patients or their proxies.
Overall adherence to quality indicators was 55 percent. Adherence was high to medical quality indicators such as stroke, medication management, and continuity of care. Indicators at the low end of adherence included end-of-life care, urinary incontinence inquiry, and an exercise recommendation with a new diagnosis of osteoarthritis. Quality indicators that focused on treatment (acute care) had the highest adherence followed by those focused on follow-up (chronic care), diagnosis, and prevention. In all categories, the pass rate was significantly lower for geriatric conditions than for general medical conditions.
The authors conclude that care of vulnerable older adults is deficient in important geriatric conditions such as falls, dementia, and urinary incontinence. Physicians need to develop skills in cognitive and gait evaluation, and the health care system needs to better highlight these important issues. ACOVE appears to be a useful comprehensive tool to assess the effectiveness of health care interventions.
An editorial in the same journal highlights the impact of frailty and other geriatric conditions with serious consequences that can be improved or avoided by specific preventive measures or treatments. The focus of physicians on acute care rather than chronic disease management and preventive care does not meet the needs of the vulnerable elderly population. Existing systems of care are probably a barrier to the provision of good geriatric care, even in a managed care environment committed to maximizing preventive and coordinated chronic care. Reimbursement and patterns of care need to change.
Wenger NS, et al. The quality of medical care provided to vulnerable community-dwelling older patients. Ann Intern Med November 4, 2003;139:740–7, and Fried LP. Establishing benchmarks for quality care for an aging population: caring for vulnerable older adults [Editorial]. Ann Intern Med. November 4, 2003;139:784–7.
editor’s note: Preventing disability in older adults is a challenge. The ability to perform basic and instrumental activities of daily living can decrease illness. Comprehensive geriatric assessments can delay the onset of disability and decrease permanent nursing home stays. The best way to perform these assessments and to successfully intervene is likely to be a live-in geriatric evaluation and management center, but this intervention is expensive and disruptive for patients who are living at home. Annual in-home geriatric assessment with quarterly visits by geriatric nurses also delays disability in persons without impairment. However, even these programs are not readily reimbursable by health care payers.
More practical is the intervention undertaken by Boult and colleagues, in which patients 70 years or older who were at high risk for hospital admission received an ambulatory comprehensive assessment followed by interdisciplinary primary care. This effort resulted in a slower decline of functional status, a decrease in health-related restrictions on daily activities, and a decreased rate of depression.1 Risk factors that can predict functional status decline include depression, cognitive impairment, comorbid conditions (the number of chronic medical conditions), reduced observed lower-extremity performance, low or high body mass index, low physical activity, poor self-rated health, smoking, low frequency of social contact, and poor self-reported vision.2—r.s.
1. Boult C, Boult LB, Morishita L, Dowd B, Kane RL, Urdangarin CF. A randomized clinical trial of outpatient geriatric evaluation and management. J Am Geriatr Soc. 2001;49:351–9.
2. Stuck AE, Walthert JM, Nikolaus T, Büla CJ, Hohmann C, Beck JC. Risk factors for functional status decline in community-living elderly people: a systematic literature review. Soc Sci Med. 1999;48:445–69.
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