Shortfalls Found in Health Care For Seniors

People 65 and older with health problems that make them vulnerable to losing their independence and ability to carry out daily activities fail to receive recommended medical care for age-related conditions about two-thirds of the time,

Also, older patients and their families need to become better informed about geriatric health care to ensure that older patients are getting proper care, according to a recent study by RAND Health.

The health care system must make a major effort to improve primary care physicians' identification and treatment of diseases of aging such as dementia, mobility disorders and urinary incontinence, say the researchers.

The study, published in the Annals of Internal Medicine, evaluated health care using quality indicators developed by the Assessing the Care of Vulnerable Elders (ACOVE) project.

A "sentinel call" for improving care for vulnerable seniors

About one-third of senior citizens in the United States fall into the vulnerable category. Researchers found that such vulnerable older people who are getting health care receive the care recommended for age-related conditions only 31 percent of the time. In contrast, the same group receives recommended care for general medical conditions 52 percent of the time, according to the study.

Many studies have raised questions about the quality of the health care provided to Americans, including a large RAND study published earlier this year that found U.S. adults receive recommended health care for most common illnesses only about half the time.

The ACOVE study is the most comprehensive examination of the quality of medical care provided to vulnerable older Americans. More than 40 percent of all medical spending in the United States is for people 65 and older.

"Among a group of vulnerable older patients, we found health care was very inadequate for a number of age-related conditions," said Neil Wenger, M.D., a RAND researcher and professor of medicine at UCLA who is the lead author of the study. "With the number of Americans over 65 nearing 15 percent of our population, this study should be a sentinel call for improving the primary medical care given to older people."

Another author of the study, Paul Shekelle, M.D., Ph.D., said: "Family members and patients need to make sure that everything is being done for age-related ailments, just as they would speak up if their chest pain wasn't being attended to." Shekelle heads the federally funded Southern California Evidence-Based Practice Center at RAND and is also affiliated with the Greater Los Angeles Veterans Affairs Healthcare System.

Conditions for which vulnerable senior receive proper care

The study evaluated medical conditions that account for the majority of all medical care older patients receive and found that for most conditions care was inadequate. Here are examples of conditions for which the vulnerable elderly receive recommended care only the listed percentage of the time:

General Medical Conditions

• Ischemic heart disease – 55 percent
• Pneumonia – 49 percent
• Depression – 31 percent
• Osteoarthritis – 31 percent

  Geriatric Conditions

• Malnutrition – 47 percent
• Pressure ulcers – 41 percent
• Dementia – 35 percent
• Falls and mobility disorders – 34 percent
• Urinary incontinence – 29 percent.
• End-of-life care – 9 percent

ACOVE is a three-year collaboration between Pfizer Inc and RAND that developed and tested quality indicators to create a comprehensive geriatric assessment system to inform health care providers and empower consumers.

"High quality health care needs to be the norm, not the exception," said Robin Hertz, Ph.D., a Pfizer epidemiologist who heads Pfizer's work on ACOVE. "We need to ensure that individual needs are addressed and patients, families and physicians are armed with condition-specific information and assessment tools to improve these deficits in care."

The research was guided by independent advisory committees including individuals nominated by the American Geriatrics Society (AGS), AARP, the American Medical Association, the American College of Physicians and the National Committee for Quality Assurance.

"In no other industry would it be acceptable to meet basic standards only one-half or one-third of the time," said Richard W. Besdine, M.D., interim dean of medicine and biological sciences at Brown University and president of AGS.

Conclusions

The study's findings may suggest that primary care physicians need additional experience or training to recognize and treat the special conditions that affect older patients.

"Most of these age-related conditions are not emphasized during medical training, nor do we target physicians for training about these conditions once they are in practice," Wenger said.

In addition, many of the age-related problems examined in the study add time to office visits in order to be diagnosed and treated. In general, Medicare and other insurance programs for seniors do not pay physicians and other health providers for the extra time needed to properly assess and treat geriatric illnesses, according to Wenger.

The study found that vulnerable older patients received about the same quality of health care as other U.S. adults for a group of general medical conditions including diabetes, stroke and heart disease.

However, the quality of health care dropped off sharply for age-related illnesses. This can profoundly affect the lives of older patients by threatening their independence and leaving them unable to care for themselves.

The study, "Quality of Medical Care Provided to Vulnerable Community Dwelling Older Patients," was published in the Nov. 4, 2003, edition of the Annals of Internal Medicine. Due to copyright restrictions, the complete text of the article is not available on the RAND Web site. Members of Congress and their staffs interested in reading the entire article should contact RAND at wea@rand.org.

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