OBJECTIVES: To develop a simple method for identifying community‐dwelling vulnerable older people, defined as persons age 65 and older at increased risk of death or functional decline. To assess ...whether self‐reported diagnoses and conditions add predictive ability to a function‐based survey.
DESIGN: Analysis of longitudinal survey data.
SETTING: A nationally representative community‐based survey.
PARTICIPANTS: Six thousand two hundred five Medicare beneficiaries age 65 and older.
MEASUREMENTS: Bivariate and multivariate analyses of the Medicare Current Beneficiary Survey; development and comparison of scoring systems that use age, function, and self‐reported diagnoses to predict future death and functional decline.
RESULTS: A multivariate model using function, self‐rated health, and age to predict death or functional decline was only slightly improved when self‐reported diagnoses and conditions were included as predictors and was significantly better than a model using age plus self‐reported diagnoses alone. These analyses provide the basis for a 13‐item function‐based scoring system that considers age, self‐rated health, limitation in physical function, and functional disabilities. A score of ≥3 targeted 32% of this nationally representative sample as vulnerable. This targeted group had 4.2 times the risk of death or functional decline over a 2‐year period compared with those with scores <3. The receiver operating characteristics curve had an area of .78. An alternative scoring system that included self‐reported diagnoses did not substantially improve predictive ability when compared with a function‐based scoring system.
CONCLUSIONS: A function‐based targeting system effectively and efficiently identifies older people at risk of functional decline and death. Self‐reported diagnoses and conditions, when added to the system, do not enhance predictive ability. The function‐based targeting system relies on self‐report and is easily transported across care settings.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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.
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).
Observational cohort study.
Managed care organizations in the northeastern and southwestern United States.
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.
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).
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).
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.
Background
Congress, veterans’ groups, and the press have expressed concerns that access to care and quality of care in Department of Veterans Affairs (VA) settings are inferior to access and quality ...in non-VA settings.
Objective
To assess quality of outpatient and inpatient care in VA at the national level and facility level and to compare performance between VA and non-VA settings using recent performance measure data.
Main Measures
We assessed Patient Safety Indicators (PSIs), 30-day risk-standardized mortality and readmission measures, and ORYX measures for inpatient safety and effectiveness; Healthcare Effectiveness Data and Information Set (HEDIS®) measures for outpatient effectiveness; and Consumer Assessment of Healthcare Providers and Systems Hospital Survey (HCAHPS) and Survey of Healthcare Experiences of Patients (SHEP) survey measures for inpatient patient-centeredness. For inpatient care, we used propensity score matching to identify a subset of non-VA hospitals that were comparable to VA hospitals.
Key Results
VA hospitals performed on average the same as or significantly better than non-VA hospitals on all six measures of inpatient safety, all three inpatient mortality measures, and 12 inpatient effectiveness measures, but significantly worse than non-VA hospitals on three readmission measures and two effectiveness measures. The performance of VA facilities was significantly better than commercial HMOs and Medicaid HMOs for all 16 outpatient effectiveness measures and for Medicare HMOs, it was significantly better for 14 measures and did not differ for two measures. High variation across VA facilities in the performance of some quality measures was observed, although variation was even greater among non-VA facilities.
Conclusions
The VA system performed similarly or better than the non-VA system on most of the nationally recognized measures of inpatient and outpatient care quality, but high variation across VA facilities indicates a need for targeted quality improvement.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
CONTEXT Continuing changes in the health care delivery system make it essential
to monitor underuse of needed care, even for relatively well-insured populations.
Traditional approaches to measuring ...underuse have relied on patient surveys
and chart reviews, which are expensive, or simple single-condition claims-based
indicators, which are not clinically convincing. OBJECTIVE To develop a comprehensive, low-cost system for measuring underuse of
necessary care among elderly patients using inpatient and outpatient Medicare
claims. DESIGN A 7-member, multispecialty expert physician panel was assembled and
used a modified Delphi method to develop clinically detailed underuse indicators
likely to be associated with avoidable poor outcomes for 15 common acute and
chronic medical and surgical conditions. An automated system was developed
to calculate the indicators using administrative data. SETTING AND SUBJECTS A total of 345,253 randomly selected elderly US Medicare beneficiaries
in 1994-1996. MAIN OUTCOME MEASURES Proportion of beneficiaries receiving care, stratified by indicators
of necessary care (n = 40, including 3 for preventive care), and avoidable
outcomes (n = 6). RESULTS For 16 of 40 necessary care indicators (including preventive care indicators),
beneficiaries received the indicated care less than two thirds of the time.
Of all indicators, African Americans scored significantly worse than whites
on 16 and better on 2; residents of poverty areas scored significantly lower
than nonresidents on 17 and higher on 1; residents of federally defined Health
Professional Shortage Areas scored significantly lower than nonresidents on
16 and higher on none (P<.05 for all). CONCLUSIONS This claims-based method detected substantial underuse problems likely
to result in negative outcomes in elderly populations. Significantly more
underuse problems were detected in populations known to receive less-than-average
medical care. The method can serve as a reliable, valid tool for monitoring
trends in underuse of needed care for older patients and for comparing care
across health care plans and geographic areas based on claims data.
Background: Medicare and private plans are encouraging individuals to seek care at hospitals that are designated as centers of excellence. Few evaluations of such programs have been conducted. This ...study examines a large national initiative that designated hospitals as centers of excellence for knee and hip replacement. Objective: Comparison of outcomes and costs associated with knee and hip replacement at designated hospitals and other hospitals. Research Design: Retrospective claims analysis of approximately 54 million enrollees. Study Population: Individuals with insurance from one of the sponsors of this centers of excellence program who underwent a primary knee or hip replacement in 2007–2009. Outcomes: Primary outcomes were any complication within 30 days of discharge and costs within 90 days after the procedure. Results: A total of 80,931 patients had a knee replacement and 39,532 patients had a hip replacement of which 52.2% and 56.5%, respectively, were performed at a designated hospital. Designated hospitals had a larger number of beds and were more likely to be an academic center. Patients with a knee replacement at designated hospitals did not have a statistically significantly lower overall complication rate with an odds ratio of 0.90 (P = 0.08). Patients with hip replacement treated at designated hospitals had a statistically significant lower risk of complications with an odds ratio of 0.80 (P = 0.002). There was no significant difference in 90-day costs for either procedure. Conclusions: Hospitals designated as joint replacement centers of excellence had lower rates of complications for hip replacement, but there was no statistically significant difference for knee replacement. It is important to validate the criteria used to designate centers of excellence.
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BFBNIB, CMK, INZLJ, NMLJ, NUK, PNG, UL, UM, UPUK, ZRSKP
Background: The Centers for Medicare and Medicaid Services and many private health plans are encouraging patients to seek orthopedic care at hospitals designated as centers of excellence. No ...evaluations have been conducted to compare patient outcomes and costs at centers of excellence versus other hospitals. The objective of our study was to assess whether hospitals designated as spine surgery centers of excellence by a group of over 25 health plans provided higher quality care. Methods: Claims representing approximately 54 million commercially insured individuals were used to identify individuals aged 18-64 years with 1 of 3 types of spine surgery in 2007-2009: 1-level or 2-level cervical fusion (referred to as cervical simple fusion), 1-level or 2-level lumbar fusion (referred to as lumbar simple fusion), or lumbar discectomy and/or decompression without fusion. The primary outcomes were any complication (7 complications were captured) and 30-day readmission. The multivariate models controlled for differences in age, sex, and comorbidities between the 2 sets of hospitals. Results: A total of 29,295 cervical simple fusions, 27,214 lumbar simple fusions, and 28,911 lumbar discectomy/decompressions were identified, of which 42%, 42%, and 47%, respectively, were performed at a hospital designated as a spine surgery center of excellence. Designated hospitals had a larger number of beds and were more likely to be an academic center. Across the 3 types of spine surgery (cervical fusions, lumbar fusions, or lumbar discectomies/decompressions), there was no difference in the composite complication rate OR 0.90 (95% CI, 0.72-1.12); OR 0.98 (95% CI, 0.85-1.13); OR 0.95 (95% CI, 0.82-1.07), respectively or readmission rate OR 1.03 (95% CI, 0.87-1.21); OR 1.01 (95% CI, 0.89-1.13); OR 0.91 (95%, CI 0.79-1.04), respectively at designated hospitals compared with other hospitals. Conclusions: On average, spine surgery centers of excellence had similar complication rates and readmission rates compared with other hospitals. These results highlight the importance of empirical evaluations of centers of excellence programs.
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BFBNIB, CMK, INZLJ, NMLJ, NUK, PNG, UL, UM, UPUK, ZRSKP
Few data exist for large managed care populations on the occurrence of subsequent acute ischemic events in persons with established atherosclerotic vascular disease. We estimated the occurrence of ...secondary stroke, acute myocardial infarction (AMI), and vascular deaths among 2 large, managed care samples.
With the use of International Classification of Diseases, Ninth Revision, Clinical Modification codes, patients aged > or =40 years and with stroke, AMI, or peripheral arterial disease (PAD) were identified from administrative data of UnitedHealthcare plans during 1995-1998. Stroke, AMI, and PAD cohorts were identified within a commercial insurance sample and a Medicare sample. Cumulative occurrences of subsequent stroke, AMI, or vascular death were estimated by survival analysis.
In the stroke commercial cohort (n=1631; mean age, 62.1 years), cumulative occurrence of subsequent events was 4.2%, 6.5%, 9.8%, and 11.8% at 0.5, 1, 2, and 3 years, respectively; cumulative secondary event occurrence in the AMI commercial cohort (n=6458; mean age, 56.0 years) was 3.5%, 4.8%, 7.3%, and 8.5% and in the PAD commercial cohort (n=5813; mean age, 59.2 years) was 1.5%, 2.8%, 4.8%, and 6.5%, respectively. Cumulative secondary event occurrences were even higher in stroke (n=1518; mean age, 79.5 years), AMI (n=2197; mean age, 76.2 years), and PAD (n=5033; mean age, 76.6 years) cohorts of the Medicare sample: 18.1%, 17.0%, and 8.7%, respectively, at 3 years. More than 75% of each stroke cohort's secondary events were strokes; more than 75% of each AMI cohort's secondary events were AMIs. Of the PAD cohorts' secondary events, 27% to 39% were strokes, 48% to 57% were AMIs, and 13% to 16% were vascular deaths.
Among these managed care enrollees with existing atherosclerotic vascular disease, subsequent ischemic events represent a significant symptomatic disease burden. Given these findings, it is very important to determine whether secondary prevention strategies are being effectively used to manage patients with diagnosed atherosclerosis.
OBJECTIVE: To identify a set of geriatric conditions as optimal targets for quality improvement to be used in a quality measurement system for vulnerable older adults.
DESIGN: Discussion and two ...rounds of ranking of conditions by a panel of geriatric clinical experts informed by literature reviews.
METHODS: A list of 78 conditions common among vulnerable older people was reduced to 35 on the basis of their (1) prevalence, (2) impact on health and quality of life, (3) effectiveness of interventions in improving mortality and quality of life, (4) disparity in the quality of care across providers and geographic areas, and (5) feasibility of obtaining the data needed to test compliance with quality indicators. A panel of 12 experts in geriatric care discussed and then ranked the 35 conditions on the basis of the same five criteria. We then selected 21 conditions, based on panelists' iterative rankings. Using available national data, we compiled information about prevalence of the selected conditions for community‐dwelling older people and older nursing home residents and estimated the proportion of inpatient and outpatient care attributable to the selected conditions.
RESULTS: The 21 conditions selected as targets for quality improvement among vulnerable older adults include (in rank order): pharmacologic management; depression; dementia; heart failure; stroke (and atrial fibrillation); hospitalization and surgery; falls and mobility disorders; diabetes mellitus; end‐of‐life care; ischemic heart disease; hypertension; pressure ulcers; osteoporosis; urinary incontinence; pain management; preventive services; hearing impairment; pneumonia and influenza; vision impairment; malnutrition; and osteoarthritis. The selected conditions had mean rank scores from 1.2 to 3.8, and those excluded from 4.6 to 6.9, on a scale from 1 (highest ranking) to 7 (lowest ranking). Prevalence of the selected conditions ranges from 10 to 50% among community‐dwelling older adults and from 25 to 80% in nursing home residents for the six most common selected conditions. The 21 target conditions account for at least 43% of all acute hospital discharges and 33% of physician office visits among persons 65 years of age and older. Actual figures must be higher because several of the selected conditions (e.g., end‐of‐life care) are not recorded as diagnoses.
CONCLUSIONS: Twenty‐one conditions were selected as targets for quality improvement in vulnerable older people for use in a quality measurement system. The 21 geriatric conditions selected are highly prevalent in this group and likely account for more than half of the care provided to this group in hospital and ambulatory settings. J Am Geriatr Soc 48: 363–369, 2000.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Understanding the current quality of care for posttraumatic stress disorder (PTSD) and depression delivered to service members is an important step toward improving care across the Military Health ...System (MHS). T.his report describes the characteristics of active-component service members who received care for PTSD or depression through the MHS and assesses the quality of care received using quality measures derived from administrative data
The need for better management of chronic conditions is urgent. Many health plans have developed innovative approaches to improving care for their members with chronic conditions. This report ...documents the current range of health plans’ chronic care management services, identifies best practices and industry trends, and examines factors in plans’ operating environment that limit their ability to optimize chronic care programs.
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