Takahiro Higashi

Monitoring Falls in Cohort Studies of Community-Dwelling Older People: Effect of the Recall Interval

Objectives: To determine whether the interval over which patients are asked to remember their falls affects fall reporting.

The Quality of Pharmacologic Care for Vulnerable Older Patients

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

Quality of care is associated with survival in vulnerable older patients.

Context Quality-of-care evaluation often focuses on how often patients receive certain tests or treatments. Theoretically, the content of care should predict patient survival, but the evidence is inconclusive. Contribution This study used 207 criteria to assess good care in 372 vulnerable elderly patients. When care did not meet these standards, patients were more likely to die during the 3 years of follow-up. Implications In vulnerable older patients, the content of care is associated with mortality. This finding supports the use of process measures in the evaluation of quality of care and shows that good care may prolong life. The Editors As clinicians, the public, and health systems become more aware that many Americans do not receive necessary care, the importance of measuring and improving quality of care has gained increasing attention (1-3). Although quality of care can theoretically be measured by outcomes (what happens to patients), process (what providers do) is often preferred (3-5) because process is under relatively greater control of providers, needs a shorter time frame, can directly inform improvement, and may not require statistical adjustment for severity of illness (6, 7). Typically, process measures evaluate the proportion of eligible patients who receive care as recommended (for example, the proportion of patients 65 years of age receiving pneumococcal vaccine). To be a meaningful measure of quality, a process of care must be related to improved patient outcomes. For many quality indicators, this relationship is based on evidence of efficacy from randomized, controlled trials, usually among a select patient population. However, the relationship between performance on process of care quality indicators and better health outcomes remains a largely untested assumption for general populations of patients receiving care in community settings. The lack of a demonstrated relationship between performance on process quality measures and outcome advantage in a cohort of patients has hindered the acceptance of quality indicators as a way to measure and improve health outcomes (8). The Assessing Care of Vulnerable Elders (ACOVE) project developed a set of process quality criteria that were judged by clinical experts to improve patient outcomes on the basis of clinical evidence and professional opinion (9-11). Combined with mortality information available through the National Death Index, our study evaluated the processoutcome relationship. While the development method conferred content validity on the process measures, we aimed to assess the predictive validity of the quality measurement system by examining the relationship between the quality of care received by sampled participants and their subsequent survival. Methods The ACOVE Project The ACOVE project developed and implemented a set of quality indicators that focuses on process of care for clinical conditions important in the care of vulnerable older patients. Details of the methods of selecting conditions and developing quality indicators have been described in previous reports (9, 10) 12). We selected quality indicators by using systematic reviews of the medical literature followed by deliberations by several panels of clinical experts using formal consensus methods to assess the validity of quality indicators. This process resulted in 236 quality indicators covering 22 clinical areas (continuity of care, dementia, depression, diabetes mellitus, end-of-life care, falls and mobility problems, hearing loss, heart failure, hospital care, hypertension, ischemic heart disease, malnutrition, medication management, osteoarthritis, osteoporosis, pain management, pneumonia, pressure ulcer, screening and prevention, stroke and atrial fibrillation, urinary incontinence, and vision care) across the continuum of care, including prevention, diagnosis, treatment, and follow-up. Each quality indicator contains an if clause that defines the patient who is eligible to receive it and a then clause that describes what care is recommended (for example: If a vulnerable elder has had a myocardial infarction, then he or she should be offered a -blocker). If the medical record describes a contraindication to the recommended care, the patient is not eligible for the quality indicator. Furthermore, we explicitly defined certain indicators as being not applicable, and therefore not included, when assessing the care of patients with advanced dementia or poor prognosis (13). We applied the ACOVE quality indicators to a sample of vulnerable older patients in 2 large managed care organizations, 1 in the northeastern United States and the other in the southwestern United States (11). Each managed care plan had more than 20000 senior members and contracted with a network of providers for delivery of care. Eligibility criteria included continuous enrollment in the managed care organization with no out-of-network care during the 13-month study period and no active treatment for malignant conditions except for nonmelanoma skin cancer. We identified vulnerable older persons by telephone interview using the Vulnerable Elders Survey-13 (VES-13) (14). The VES-13 is a 13-item questionnaire that produces a vulnerability score ranging from 0 to 10 based on age, self-reported health, and function. Patients with scores of 3 or higher are at 4 times the risk for death or functional decline over the next 2 years and are therefore defined as vulnerable. We excluded nonEnglish-language speakers because interviews were available only in English. Among 3207 community-dwelling patients 65 years of age and older who were randomly selected from the 2 managed care plans, we conducted screening interviews with 2278 patients (9% through proxies) and identified 475 (21%) patients as vulnerable. Among them, 420 (88%) patients consented to participate in the study and 372 (78%) patients had medical records for the 13-month period from 1 July 1998 to 31 July 1999 that were able to be abstracted. We collected all participants medical records, including those for inpatient care, outpatient care, nursing home care, home care, and mental health care. Trained nurses abstracted charts to apply quality indicators. A senior nurse reviewer assessed completed abstractions, and physician overreaders reviewed them for clinical assessment. We evaluated inter-rater reliability by reabstraction of 10% of the medical records, which contained 698 quality indicators. Agreement was 97% for quality indicator eligibility and 95% for overall quality score. We collected patient characteristics, including age, sex, cognitive function measured by the Blessed OrientationMemoryConcentration test (15), and mental health score derived from Medical Outcomes Study Short Form-36 items (16), at the time of the recruitment telephone interview. The RAND institutional review board approved the study protocol. Among the 236 ACOVE quality indicators, 207 could be implemented in the field trial either by medical record (183 indicators) or patient interview (24 indicators). Because some patients died before the interview was conducted, we used only quality indicators for which information was available in medical records. Among these, 160 quality indicators had at least 1 eligible patient; 43 focused on prevention, 42 on diagnosis, 47 on treatment, and 28 on follow-up care. These 160 quality indicators covered all 22 conditions. The Appendix Table contains the list of quality indicators used in our report, the number of eligible patients, and the pass rate for each indicator. Appendix Table. Quality Indicators Using Medical Records as the Information Source, Eligible Patients, and Pass Rates Statistical Analysis We calculated quality scores for each patient on the basis of the percentage of ACOVE quality indicators for which an eligible patient received recommended care. We obtained death, date, and cause-of-death data for ACOVE participants from the National Death Index during 3 years after the quality measurement period (from August 1999 to September 2002). We used both unadjusted and adjusted analyses to examine the link between patient survival and quality score. For the unadjusted analysis, we first divided the sample in half on the basis of quality score (that is, median and < median) and examined the difference in survival curves between patients with higher quality and patients with lower quality by using the log-rank test. Second, we calculated survival for 10 equal intervals of quality score from the lowest quality score to the highest quality score in the sample and graphically assessed the graded relationship between quality score and survival. We used the Cox proportional hazards survival model in adjusted analyses. Because the proportional hazards assumption for the multivariate survival analysis did not hold for the entire observation period, we used a piecewise model that allowed the coefficients for quality to vary between 500 days or less and more than 500 days, as suggested by the KaplanMeier survival curve in the unadjusted analysis. Covariates included sex, VES-13 score (including age), mental health, number of hospitalizations and office visits during the quality measurement period, and number of conditions that patients had during the quality measurement period among 13 comorbid conditions (dementia, depression, diabetes mellitus, heart failure, hypertension, ischemic heart disease, osteoarthritis, osteoporosis, pressure ulcer, atrial fibrillation, urinary incontinence, chronic obstructive pulmonary disease, and chronic renal failure). The mental health score ranged from 1 to 6, and we created 3 categories on the basis of the score (<2, very good; 2 to 3, good; and >3, fair). An indicator variable designated patients who were not interviewed for mental health items because of cognitive impairment. To further examine a plausible mechanism for the qualitysurvival link, we examined the relationship between survival and hi

Multimorbidity is associated with better quality of care among vulnerable elders

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.

A Practice-Based Intervention to Improve Primary Care for Falls, Urinary Incontinence, and Dementia

OBJECTIVES: To determine whether a practice‐based intervention can improve care for falls, urinary incontinence, and cognitive impairment.

Predictors of Overall Quality of Care Provided to Vulnerable Older People

Objectives: Prior research shows that the quality of care provided to vulnerable older persons is suboptimal, but little is known about the factors associated with care quality for this group. In this study, the influences of clinical conditions, types of care processes, and sociodemographic characteristics on the quality of care received by vulnerable older people were evaluated.

The effect of a quality improvement initiative on the quality of other aspects of health care : The law of unintended consequences?

Problem:Policymakers and clinicians are concerned that initiatives to improve the quality of care for some conditions may have unintended negative consequences for quality in other conditions. Objective:We sought to determine whether a practice redesign intervention that improved care for falls, incontinence, and cognitive impairment by an absolute 15% change also affected quality of care for masked conditions (conditions not targeted by the intervention). Design, Setting, and Participants:Controlled trial in 2 community medical groups, with 357 intervention and 287 control patients age 75 years or older who had difficulty with falls, incontinence, or cognitive impairment. Intervention:Both intervention and control practices implemented case-finding for target conditions, but only intervention practices received a multicomponent practice-change intervention. Quality of care in the intervention practices improved for 2 of the target conditions (falls and incontinence). Main Outcome Measures:Percent of quality indicators satisfied for a set of 9 masked conditions measured by abstraction of medical records. Results:Before the intervention, the overall percent of masked indicators satisfied was 69% in the intervention group and 67% in the control group. During the intervention period, these percentages did not change, and there was no difference between intervention and control groups for the change in quality between the 2 periods (P = 0.86). The intervention minus control difference-in-change for the percent of masked indicators satisfied was 0.2% (bootstrapped 95% confidence interval, −2.7% to 2.9%). Subgroup analyses by clinical condition and by type of care process performed by the clinician did not show consistent results favoring either the intervention or the control group. Conclusion:A practice-based intervention that improved quality of care for targeted conditions by an absolute 15% change did not affect measurable aspects of care on a broad set of masked quality measures encompassing 9 other conditions.

Comparison of Administrative Data and Medical Records to Measure the Quality of Medical Care Provided to Vulnerable Older Patients

Background:Administrative data are used to determine performance for publicly reported in health plan “report cards,” accreditation status, and reimbursement. However, it is unclear how performance based on administrative data and medical records compare. Methods:We compared applicability, eligibility, and performance on 182 measures of health care quality using medical records and administrative data during a 13-month period for a random sample of 399 vulnerable older patients enrolled in managed care. Results:Of 182 quality indicators (QIs) spanning 22 conditions, 145 (80%) were applicable only to medical records and 37 (20%) to either medical records or administrative data. Among 48 QIs specific to geriatric conditions, all were applicable to medical records; 2 of these also were applicable to administrative data. Eligibility for the 37 QIs that were applicable to both medical records and administrative data was similar for both data sources (94% agreement, κ = 0.74). With the use of medical records, 152 of the 182 the QIs that were applicable to medical records were triggered and yielded an overall performance of 55%. Using administrative data, 30 of the 37 QIs that were applicable to administrative data were triggered and yielded overall performance of 83% (P < 0.05 vs. medical records). Restricting to QIs applicable to both data sources, overall performance was 84% and 83% (P = 0.21) for medical records and administrative data, respectively. Conclusions:The number and spectrum of QIs that can be measured for vulnerable elderly patients is far greater for medical records than for administrative data. Although summary estimates of health care quality derived from administrative data and medical records do not differ when using identical measures, summary scores from these data sources vary substantially when the totality of care that can be measured by each data source is measured.

The organization and financing of end-stage renal disease treatment in Japan

End-stage renal disease (ESRD) affects 230,000 Japanese, with about 36,000 cases diagnosed each year. Recent increases in ESRD incidence are attributed mainly to increases in diabetes and a rapidly aging population. Renal transplantation is rare in Japan. In private dialysis clinics, the majority of treatment costs are paid as fixed fees per session and the rest are fee for service. Payments for hospital-based dialysis are either fee-for-service or diagnosis-related. Dialysis is widely available, but reimbursement rates have recently been reduced. Clinical outcomes of dialysis are better in Japan than in other countries, but this may change given recent ESRD cost containment policies.

Health-Related Quality of Life Among Japanese Women With Iron-Deficiency Anemia

Iron-deficiency anemia (IDA) is a common disease in females of childbearing age. Although iron supplementation quickly improves laboratory-measured parameters, its effect on health-related quality of life is unknown. Here, we conducted a prospective follow-up study to evaluate health-related quality of life in pre-menopausal women diagnosed with IDA. A convenience sample of 92 patients who visited Tokai University Hospital and three other affiliated hospitals were asked to fill out the Medical Outcome Study 36-item short-form health survey (SF-36) during the course of treatment (baseline, and 1 and 3xa0months after the start of treatment). At baseline, vitality and general health scores were significantly lower than the Japanese national norms. After the start of therapy, however, a significant improvement was seen in all domain scores except role emotional (RE), and at 3xa0months all eight scores were comparable to or greater than the national norms. In particular, physical functioning and vitality scores of patients with a lower hemoglobin level ( < 9.0xa0g/dl) at baseline showed a dramatic improvement. Iron supplementation in IDA patients improves not only hemoglobin levels, but also physical function, vitality, and general health perception.