RAND Review
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Community Efforts Can Ameliorate Poor Quality of Care
Medical Care, Medications Found Lacking Among Vulnerable Elderly
Nearly simultaneous with its reports on the poor quality of care nationwide, RAND released two additional reports on the poor quality of care received by America’s vulnerable elders. The two reports define “vulnerable elders” as people 65 and older with health problems that make them vulnerable to losing their independence or even to dying. Roughly one-third of U.S. senior citizens fall into this vulnerable category.
Quality of care for this population is deficient in several ways, according to the reports. Vulnerable elders
- receive recommended care for their age-related conditions only 31 percent of the time
- receive recommended care for other medical conditions only 52 percent of the time
- receive recommended medications for all conditions only 50 percent of the time.
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The first report, published in the Nov. 4 edition of the Annals of Internal Medicine, concluded that “care for geriatric conditions is much less optimal than care for general medical conditions.” Geriatric conditions include dementia, mobility disorders, and urinary incontinence.
The study, which evaluated the medical conditions accounting for the majority of all medical care that older patients receive, found that care was inadequate for most conditions. There was also a wide variation in quality by condition, ranging from 9 percent of recommended care delivered for end-of-life care to 82 percent for stroke care (see figure). End-of-life care deals largely with the documentation of advance directives indicating treatment preferences and the incorporation of those preferences into the care delivered during the final days of life.
Many of the skills needed to carry out the processes of care for age-related conditions “may not be as well taught in medical school and primary care residencies” as other, more technical skills, according to the study. It concluded that efforts to improve care for vulnerable elders should “focus on the geriatric conditions that profoundly influence functional status.”
The second report, published six months later in the May 4 edition of the Annals of Internal Medicine, examined the quality of pharmacologic care for vulnerable elders at two U.S. managed care organizations. One is located in the northeast and one in the southwest.
The study found that physicians avoided prescribing inappropriate medications 97 percent of the time. However, physicians prescribed necessary medications only 50 percent of the time, provided patients with proper education and documentation about the medications 81 percent of the time, and properly monitored medicated patients just 64 percent of the time.
Health policy efforts have focused on finding ways to pay for the medications needed by older patients but not on ways to improve medication management. “Improvement in access to medications without quality assurance may result in a mere increase in care without change in outcomes,” the study warned.
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