Catherine H. MacLean

American College of Rheumatology 2008 Recommendations for the Use of Nonbiologic and Biologic Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis

Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to these guidelines and recommendations to be voluntary, with the ultimate determination regarding their application to be made by the physician in light of each patient’s individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed or endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.

The Vulnerable Elders Survey: A Tool for Identifying Vulnerable Older People in the Community

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.

Systematic Review: Comparative Effectiveness of Treatments to Prevent Fractures in Men and Women with Low Bone Density or Osteoporosis

Context Sorting through the proven benefits and harms of the agents available for treating osteoporosis is difficult. Contribution This systematic review of 76 randomized trials and 24 meta-analyses found good evidence that multiple agents, including alendronate, zoledronic acid, and estrogen, prevented vertebral and hip fractures more than placebo. Harms included increased risk for thromboembolic events with raloxifene, estrogen, and estrogenprogestin and increased gastrointestinal symptoms with bisphosphonates. No large trials directly compared 2 or more agents and established superiority of any agent. Implication Available data insufficiently characterize the benefits and harms of various therapies for osteoporosis relative to one another. The Editors Osteoporosis is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture (1). Approximately 44 million people in the United States are affected by osteoporosis and low bone mass (2). The clinical complications include fractures, disability, and chronic pain. About 54% of women age 50 years or older will have an osteoporotic fracture during their lifetime (3). Furthermore, approximately 4% of patients older than 50 years of age who have a hip fracture die while in the hospital and 24% die within 1 year after the hip fracture (4). The economic burden of osteoporosis is large and growing. Most estimates are based on the cost of fracture alone: A 1995 estimate of costs incurred by osteoporotic fractures in the United States was

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

13.8 billion (5). A 2003 review estimated the total costs in the United States at

The Quality of Pharmacologic Care for Vulnerable Older Patients

17 billion (6). Although the bulk of these costs were incurred by retired individuals older than age 65 years, direct costs and work loss are significant among employed postmenopausal women (7). The increasing prevalence and cost of osteoporosis have heightened interest in the efficacy and safety of the many agents available to treat the loss of bone mineral associated with osteoporosis. This systematic review, developed under the Agency for Healthcare Research and Quality (AHRQ) Effective Health Care Program, describes the benefits in fracture reduction and the harms from adverse events among and within the various classes of pharmacotherapies for osteoporosis. The agents evaluated were bisphosphonates (alendronate, etidronate, ibandronate, pamidronate, risedronate, and zoledronic acid), calcitonin, estrogen, teriparatide, selective estrogen receptor modulators (raloxifene and tamoxifen), testosterone, and vitamins (vitamin D) and minerals (calcium). Methods We followed a standardized protocol for the review. The full technical report (8) provides detailed methods, evidence tables, and risk estimates for individual studies. The full report also enumerates studies included in the meta-analyses described in this review. Data Sources and Study Selection We searched MEDLINE (1966 to December 2006), the ACP Journal Club database, the Cochrane Central Register of Controlled Trials (no date limits), the Cochrane Database of Systematic Reviews (no date limits), and the Web sites of the National Institute for Health and Clinical Excellence (no date limits) and Health Technology Assessment Programme (January 1998 to December 2006) for materials pertaining to the specified agents, limiting our searches to English-language publications and human studies. We first identified systematic reviews and meta-analyses of trials that reported pooled estimates of the effect of the agents on fracture risk. When such reviews were identified for specific agents, we truncated our searches for randomized trials to include only those published after the last search date used in the review or meta-analysis. We manually searched reference lists of all review articles obtained for any reports of original research not already identified, and we reviewed U.S. Food and Drug Administration (FDA) medical and statistical reviews, scientific information packets from pharmaceutical companies, and additional studies recommended by our technical expert panel and by stakeholders during a public review period. To supplement the information in systematic reviews on estrogen, we reviewed the Womens Health Initiative and Heart and Estrogen/progestin Replacement Study trials, as suggested by our technical expert panel. Finally, we conducted an additional search for large observational studies that reported any of the following adverse events: 1) cardiovascular events (myocardial infarction and stroke); 2) thromboembolic events (pulmonary embolism and venous thromboembolic events); 3) malignant conditions (breast cancer, colon cancer, lung cancer, and osteosarcoma); 4) upper gastrointestinal events (perforations, ulcers, bleeding, and esophageal ulcerations); and 5) osteonecrosis. The search was updated for this paper, but not for the full report, by searching MEDLINE (1 January 2007 to 10 November 2007) for large clinical trials that reported fracture outcomes for the specified agents. For information on efficacy, we selected meta-analyses that reported pooled risk estimates for fracture and randomized trials that compared any of the agents with placebo or with each other and reported fracture outcomes. For information on harms, we selected systematic reviews, randomized trials, and large casecontrol or cohort studies with more than 1000 participants. We also reviewed cases of osteonecrosis at AHRQs request. Data Extraction and Study Quality Two physicians independently abstracted data about study populations, interventions, follow-up, and outcome ascertainment by using a structured form. For each group in a randomized trial, a statistician extracted the sample size and number of persons who reported fractures. Two reviewers, under the supervision of the statistician, independently abstracted information about adverse events. Disagreements were resolved by the statistician or the principal investigator. Adverse events were recorded onto a spreadsheet that identified numbers of participants in each trial group and the description of the adverse event as listed in the original article. Each event was counted as if it represented a unique individual. Because an individual may have experienced more than 1 event within a category of adverse events (for example, both stroke and myocardial infarction), this assumption may have overestimated the number of people who had an adverse event in that category. If a trial report mentioned a particular type of adverse event but did not report data on it, we did not include the trial in that particular events analysis. In other words, we did not assume an occurrence of zero events unless it was specifically reported as such. By taking this approach, we may have overestimated the number of patients for whom a particular adverse event was observed. We used predefined criteria to assess the quality of systematic reviews and randomized trials, based on internal and external validity assessment detailed in the QUOROM (Quality of Reporting of Meta-Analyses) statement (9), and items related to randomization, blinding, and accounting for withdrawals and dropouts (10, 11). Each element is detailed in appendices to the full report (8). For this review, we characterized the overall strength of evidence for estimating fracture risk as good, fair, or weak on the basis of the characteristics previously described, as well as the number of studies, total number of participants across studies, whether fractures were a primary outcome, reproducibility of results across studies, and precision of the CIs surrounding the point estimates. Evidence was classified as good if the total sample size was greater than 1000, the results across all studies were consistent, and the studies were of high methodological quality. Evidence was classified as fair if results were inconsistent across the studies. The evidence was classified as weak if no studies assessed fracture as a primary outcome, the total sample size across studies was less than 500, and the CIs around the point estimates were wide and crossed null. Data Synthesis and Statistical Analysis Comparisons of interest were single agent versus placebo and single agent versus another agent for agents within the same class and across classes. We also compared estrogenprogestin versus placebo or single drugs. Studies that included either calcium or vitamin D in all study groups were classified as comparisons between the other agents in each group; for example, alendronate plus calcium versus risedronate plus calcium would be classified as alendronate versus risedronate. In this review, we summarize data on vertebral, nonvertebral, and hip fractures; data on total, wrist, and humerus fractures are included in the full report (8). The number of people with at least 1 fracture was our primary outcome of interest. Because fractures rarely occurred and zero events were often observed in at least 1 treatment group, we calculated odds ratios (ORs) by using the Peto method (12). Trials with zero events in both groups have an undefined OR. Because fractures are rare events, the OR approximates the relative risk (RR) for fracture. We combined data from multiple study groups in an individual study to calculate a single OR for comparisons of interest. In these instances, the same outcome had been reported for each group, and the individuals in each group were unique. For example, to develop an OR for the risk for vertebral fractures regardless of dose, we combined the participants in the various dose groups and compared them with those in the placebo group. We conducted the meta-analysis by using StatXact PROCs (Cytel, Cambridge, Massachusetts) for SAS software (SAS Institute, Cary, North Carolina). Recognizing that characteristics of the study population may affect risk for fracture, we defined risk groups to categorize the

Multimorbidity is associated with better quality of care among vulnerable elders

Context Many Americans 65 years of age and older are at risk for functional decline, yet we know little about the quality of care for geriatric conditions. Contribution This study used a 13-item survey about functional status to evaluate the care of 420 people 65 years of age and older whom the investigators identified as vulnerable to functional decline. Quality of care was highly variable from condition to condition but was generally better for general medical conditions, such as diabetes, than for geriatric conditions, such as incontinence. Implications Efforts to improve care for vulnerable elders should focus on the geriatric conditions that profoundly influence functional status. The Editors The quality of care among patients 65 years of age and older has not been extensively investigated, and most existing studies have focused on general adult medical conditions. This is surprising, considering that more than 40% of all medical expenditures are for persons 65 years of age and older (1). The most comprehensive study to date of quality of care among older patients evaluated 24 process indicators among U.S. Medicare beneficiaries in all 50 states between 1997 and 1999 (2). Care for acute myocardial infarction, heart failure, stroke, and pneumonia was evaluated by using inpatient medical records. Pneumonia, breast cancer, and diabetes indicators were evaluated by using survey and Medicare claims data. The investigators found that the percentage of patients receiving appropriate care varied widely by measure and state. Several other studies of older patients evaluated cardiovascular conditions, diabetes, or aspects of preventive care and medication use (3-10). No study, however, has assessed the quality of medical care provided for geriatric conditions that profoundly affect the lives of vulnerable older patients. Furthermore, surveys find that older persons often prioritize function and comfort over disease treatment and prolongation of life (11). Quality-of-care measurement for older patients that examines only a few conditions and only indicators aimed at prolonging life yields an incomplete assessment because it ignores other conditions and aspects of care that are of equal or even greater importance to older patients. For this reason, we developed a quality assessment system that assesses more conditions. Together, these conditions account for a majority of all of the care older patients receive (12) and include several geriatric syndromes. We used this quality assessment system to evaluate the care provided to a sample of vulnerable elders at increased risk for death or functional decline. Methods The Assessing Care of Vulnerable Elders (ACOVE) project developed and applied a quality assessment system for vulnerable older persons. The assessment system aimed to develop quality indicators (QIs) that cover the spectrum of care for these patients. Indicators were implemented by using medical record abstraction and patient interview. The ACOVE Quality-of-Care Assessment System The ACOVE investigators developed a system of QIs to cover the most important conditions vulnerable elders encounter in all care venues. This system focused on processes (care behaviors) rather than outcomes for 2 reasons. First, although most agree that outcomes should be adjusted for risk when quality is measured, there is little consensus regarding the best severity measurement system (13). Second, measurement of processes of care is thought to be a more direct assessment of quality than measurement of outcomes (14). The process measures were selected to represent the various domains of care: screening and prevention, diagnosis, treatment, and follow-up. The development of the assessment system was guided by a Policy Advisory Committee, which helped to direct the focus toward practical applications, and by a Clinical Committee, which provided clinical expertise for development and monitored the assembly of the QIs into a comprehensive system (15). The methods for selecting conditions and developing the QIs have been described in detail elsewhere (12, 16). In brief, the Clinical Committee used the criteria of prevalence, impact, effectiveness of prevention or treatment, need for quality improvement, feasibility of measurement, and geriatric niche in a formal group rating process to identify 22 target conditions for quality improvement (12). For each of the 22 conditions, we developed a set of evidence-based QIs for vulnerable elders using a combination of systematic reviews and expert judgment (16). Of 420 proposed QIs, the 2 expert panels, the Clinical Committee, and the American College of Physicians Task Force on Aging accepted 236 as valid indicators; these were assembled into the ACOVE QI set (17). The 236 QIs covered the domains of care as follows: Sixty-one (26%) focused on screening and prevention, 50 (21%) focused on diagnosis, 84 (36%) focused on treatment, and 41 (17%) focused on follow-up and continuity of care. Examples of ACOVE QIs for each condition are presented in Table 1. Table 1. Examples of Assessing Care of Vulnerable Elders Quality Indicators Patients and Data Collection Using the ACOVE QI set, we assessed care provided to seniors who were enrolled in 2 managed care organizations. These patients were defined as vulnerable on the basis of self-report or proxy report on a brief, 13-item screening survey (Vulnerable Elders-13 [VE-13] Survey [18]). Vulnerable elders, identified by this function-based survey, are community-dwelling persons 65 years of age and older who have 4 times the risk for functional decline or death over the next 2 years compared with individuals not identified as vulnerable (18). Each managed care organization, 1 in the northeastern United States and the other in the southwestern United States, had more than 20 000 elderly enrollees and contracted with a network of providers to deliver care. Eligibility criteria included continuous enrollment in the managed care organization for at least 13 months and no out-of-plan care or active treatment for malignant conditions (excluding nonmelanoma skin cancer) during this period. A random sample of 3207 community-dwelling elderly adults was drawn from eligible persons in each managed care organization by using a random-number generator. Vulnerable elders were identified by using the VE-13 Survey as part of a telephone interview. Patients who did not speak English were not eligible to participate. The RAND Institutional Review Board approved the study protocol. Medical Record Review Using administrative data, we identified all inpatient and outpatient medical care received by study participants during the 13-month period of 1 July 1998 to 31 July 1999. Medical records were requested from primary care and specialist providers (including eye care and mental health providers), acute care hospitals, skilled-nursing facilities, home health agencies, and facilities providing outpatient services (for example, physical therapy). Identifying information of patients and providers was removed from the medical records. Trained nurses with previous experience in quality assessment performed medical record abstraction. Abstractors were provided with written abstraction guidelines and real-time consultation with a senior nurse reviewer. The abstractor considered all of a patients records when assessing whether he or she was eligible for and received the indicated care processes. In other words, information on eligibility for a QI could have been derived from 1 record (such as an outpatient note) while the care process was delivered and documented in another setting (for example, inpatient medical record). If the care process was performed in the defined time interval, care was scored as complying with the QI. The senior nurse reviewer also assessed each completed medical record abstraction. Physicians reviewed QIs that required a more detailed level of clinical assessment. Examples include whether the elements of a delirium evaluation had been completed or whether an adequate intervention was performed for hyperlipidemia. An ophthalmologist evaluated selected data elements addressing vision care. Ten percent of all records were reabstracted to evaluate reliability of the abstraction process. Exact agreement on QI eligibility and score was 95%. (For details of abstractor preparation and abstraction materials, see the Appendix.) Quality-of-Care Interview A quality-of-care interview was conducted to ask study participants (or, if participants were incapable of responding, their proxies) about aspects of their care that might not be captured in the medical record (for example, physicianpatient counseling). On the basis of conditions and medications reported during the interview, patients were asked about specific processes of care they had received. Patients were also asked about care preferences that might affect the applicability of QIs. In addition, the interview included demographic questions and functional status items. The quality-of-care interview was conducted by telephone between August and October 2000 and required, on average, 44 minutes to complete. Statistical Analysis Of the 236 QIs, we were able to evaluate 207 using chart abstraction (n = 185 [89%]) or interview (n = 22 [11%]). Interview was used to score QIs for data elements that we did not collect from the medical record. A QI was scored for a patient if he or she satisfied the IF statement of the QI and thus was eligible to receive the specified care process (Table 1). A score of 1 was awarded if the care process was carried out, and a score of 0 was assigned if it was not. For QIs that included several triggering events, a score between 0 and 1 was possible. If the medical record indicated that the patient declined the care process, the QI was considered to be passed (the care was credited in both the numerator and the denominator of the indicator score). On the other hand, if the patient had a pre

Selecting Target Conditions for Quality of Care Improvement in Vulnerable Older Adults

Context Prescription and management of medications are important issues for older adults. Contribution Among elders enrolled in two managed care organizations, most quality problems were related to failure to prescribe indicated medications; failure to monitor medications; and failure to provide medication along with proper documentation and education in concert with other physicians. Implications Prescribing inappropriate medications for older adults is less of an issue than other aspects of drug therapy. Quality improvement efforts should focus on avoiding errors of omission in prescribing indicated medications, monitoring, patient education, and follow-up. The Editors Pharmacotherapy is an essential component of medical treatment for older patients, but medications are also responsible for many adverse events in this group. Ninety percent of people 65 years of age or older take at least one medication (1). This age group, which represents only 13% of the population, accounts for one third of all prescription drug expenditures in the United States (2). Many older persons take multiple drugs for the treatment of several conditions, which increases the chance of adverse drug reactions, drugdrug interactions, and drugdisease interactions. The frequency of adverse drug events in elderly outpatients ranges from 10% to 35%, depending on the setting (3-5). Recognizing the magnitude of medication-related issues, panels of geriatric experts rate medication problems among the most important quality-of-care problems for older patients (6-8). Reflecting the severity and frequency of adverse drug events in older patients, many investigations have focused on the appropriateness of medication prescribing to elderly persons. Implicit review mechanisms include the Medication Appropriateness Index, which consists of 10 medication characteristics (including indication, effectiveness, and dosage) that a trained pharmacist reviewer can judge as appropriate, marginally appropriate, or inappropriate. An application of the Medication Appropriateness Index to elderly veterans taking 5 or more prescription medications found that 74% had at least 1 inappropriate aspect to their prescriptions (9, 10). Reviews using explicit criteria usually focus on medications that should be avoided in the care of older patients. The list of medications to avoid, which was developed by Beers and colleagues on the basis of a formal consensus of geriatric experts (11-13), has been applied to various groups of patients, revealing a high prevalence of inappropriate drug use (14-20). In addition, explicit criteria about drugdrug interactions, treatment duration, and drug contraindications were created by Tamblyn and colleagues and applied to medications prescribed to older patients in Canada (21). They found that more than half of older patients took at least one high-risk medication. Health policy efforts, on the other hand, have focused predominantly on finding ways to pay for the medication needed by older patients. Proposals aim to improve access to pharmacologic care but do not strive to develop mechanisms to evaluate or improve the quality of medication management for older patients. Improvement in access to medications without quality assurance may result in a mere increase in care without change in outcomes. To provide a more comprehensive evaluation of the quality of pharmacologic care for older patients, we systematically evaluated medication management for a sample of older patients by taking advantage of a set of explicit process of care quality indicators developed and implemented in the Assessing Care of Vulnerable Elders (ACOVE) project (22). Whereas the earlier ACOVE analysis described overall quality of care and compared care quality for geriatric and medical conditions, this study focuses on pharmacologic care and identifies improvement needs in medication management. Our quality evaluation covered the continuum of pharmacologic care, from recognizing the indications for medications to choosing medication, prescribing appropriately, educating and documenting, and monitoring after prescribing. Methods The ACOVE project developed a set of explicit quality indicators to evaluate the care provided to vulnerable older persons (22-24). The system focuses on processes of care within the domains of prevention, diagnosis, treatment, and follow-up and covers the spectrum of care contained in 22 conditions that are important in the care of older patients (7). The methods for selecting conditions and developing the quality indicators are described in detail elsewhere (7, 23). Methods included systematic literature reviews and multiple layers of expert judgment (23). The literature review resulted in proposal of candidate quality indicators, which were reviewed by an expert panel that rated each of the proposed quality indicators for validity and feasibility. This set was modified and approved by a clinical committee of national geriatric experts and by the American College of Physicians Task Force on Aging (24). From the final ACOVE set of quality indicators, 43 quality indicators (Table 1 and Appendix Table) that pertained to pharmacologic care and had more than 5 eligible patients are included in this analysis. Table 1. Medication Quality Indicators, Number of Eligible Patients, and Pass Rates Patients and Data Collection We assessed care provided to older persons who were enrolled in 2 managed care organizations. Each managed care organization, one in the U.S. Northeast and the other in the Southwest, had more than 20 000 senior enrollees and contracted with a network of providers to deliver care. A random sample of community-dwelling persons 65 years of age or older was drawn from enrollees in each managed care organization. Eligibility criteria included continuous enrollment in the managed care organization for at least 13 months, no out-of-plan care, and no active treatment for malignant conditions (excluding nonmelanoma skin cancer) during the period. In addition, persons who did not speak English were excluded because our interview instruments were not available in other languages. Among the enrollees, we targeted vulnerable elders, defined as persons 65 years of age and older who are at increased risk for death or functional decline. Vulnerable elders were identified on the basis of self-report (or proxy report) by using a brief screening survey (the Vulnerable Elders-13 [VE-13] Survey [25]) administered by telephone. The RAND Institutional Review Board approved the study protocol. Data were derived mainly from abstracting medical records. For participating patients, we identified all inpatient and outpatient medical records during the 13-month period of 1 July 1998 to 31 July 1999. These medical records were abstracted by trained nurses with experience in quality assessment. The abstractor considered all of a patients medical records when assessing whether a patient was eligible for and received the indicated care processes. Information on eligibility for a quality indicator could be derived from one medical record (such as a primary care physician starting an appropriate antidepressant) and the care process delivered and documented from records in another setting (such as a psychiatric consultant escalating the antidepressant dosage in response to lack of improvement). A senior nurse-reviewer assessed each completed medical record abstract, and physician overreaders reviewed quality indicators that required a clinical assessment, such as whether there was follow-up to newly started long-term therapy with a medication or whether newly started therapy with a highly anticholinergic drug had acceptable alternatives. We evaluated inter-rater reliability by re-abstracting a random sample of 10% of the medical records. These records contained 698 quality indicators; 97% had identical eligibility and 95% demonstrated identical eligibility and score. Details of study enrollment and data collection can be found elsewhere (22). Because some aspects of care might not be adequately captured in the medical record (for example, patient education about medications), these data were supplemented by a quality-of-care interview with study participants (or, if necessary, their proxies). During the interview, patients were asked to list all of their medications. On the basis of conditions and medications reported during the interview, patients were asked about specific processes of care they had received. The interview was conducted by telephone between August and October 2000. To minimize recall bias, we asked about most recent care when implementing quality indicators that may include multiple events (for example, education about newly started therapy with a medication). Information was obtained from medical records for 37 quality indicators and from the patient interview for 6 quality indicators. For 4 quality indicators reported previously by using medical record data (22), we used interview data in this analysis because subsequent evaluation revealed that interview data on information transfer quality indicators yielded higher pass rates that were aligned with a priori hypotheses and provided more conservative estimates of quality of care. Statistical Analysis A quality indicator was scored for a patient if he or she met the eligibility criteria to receive the specified care process. The quality indicator was passed if the care process was implemented for the patient. If the medical record indicated that the patient declined the care process, the quality indicator was considered to be passed. On the other hand, if the patient had a prespecified contraindication to the care process (such as a patient with asthma who otherwise was eligible to receive a -blocker after a myocardial infarction), the patient was considered ineligible for the quality indicator. Quality scores were calculated as the proportion of eligible patients who received indicated care. I

Systematic review of the effects of n−3 fatty acids in inflammatory bowel disease

Background: Older patients with multiple chronic conditions may be at higher risk of receiving poorer overall quality of care compared with those with single or no chronic conditions. Possible reasons include competing guidelines for individual conditions, burden of numerous recommendations, and difficulty implementing treatments for multiple conditions. Objectives: We sought to determine whether coexisting combinations of 8 common chronic conditions (hypertension, coronary artery disease, chronic obstructive pulmonary disease, osteoarthritis, diabetes mellitus, depression, osteoporosis, and having atrial fibrillation or congestive heart failure) are associated with overall quality of care among vulnerable older patients. Materials and Methods: Using an observational cohort study, we enrolled 372 community-dwelling persons 65 years of age or older who were at increased risk for death or functional decline within 2 years. We included (1) a comprehensive measure (% of quality indicators satisfied) of quality of medical and geriatric care that accounted for patient preference and appropriateness in light of limited life expectancy and advanced dementia, and (2) a measure of multimorbidity, either as a simple count of conditions or as a combination of specific conditions. Results: Multimorbidity was associated with greaer overall quality scores: mean proportion of quality indicators satisfied increased from 47% for elders with none of the prespecified conditions to 59% for those with 5 or 6 conditions (P < 0.0001), after controlling for number of office visits. Patients with greater multimorbidity also received care that was better than would be expected based on the specific set of quality indicators they triggered. Conclusions: Among older persons at increased risk of death or functional decline, multimorbidity results in better, rather than worse, quality of care.

The Quality of Medical Care Provided to Vulnerable Older Patients with Chronic Pain

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.

A quality indicator set for systemic lupus erythematosus

BACKGROUND n-3 Fatty acids are purported to have health effects in patients with inflammatory bowel disease (IBD), but studies have reported mixed results. OBJECTIVE We aimed to synthesize published and unpublished evidence to determine estimates of the effect of n-3 fatty acids on clinical outcomes in IBD and whether n-3 fatty acids modify the effects of or need for treatment with other agents. DESIGN Computerized databases were searched for studies of n-3 fatty acids in immune-mediated diseases from 1966 to 2003. We also contacted experts in the nutraceutical industry to identify unpublished studies; however, none were identified. RESULTS Reviewers identified 13 controlled trials that assessed the effects of n-3 fatty acids on clinical, sigmoidoscopic, or histologic scores; rates of induced remission or relapse; or requirements for steroids and other immunosuppressive agents in Crohn disease or ulcerative colitis. Most clinical trials were of good quality. Fewer than 6 were identified that assessed the effects of n-3 fatty acids on any single outcome of clinical, endoscopic, or histologic scores or remission or relapse rates. Consistent across 3 studies was the finding that n-3 fatty acids reduce corticosteroid requirements, although statistical significance was shown in only 1 of these studies. CONCLUSION The available data are insufficient to draw conclusions about the effects of n-3 fatty acids on clinical, endoscopic, or histologic scores or remission or relapse rates.