RAND-UCLA Study Finds Significant Shortfalls in Quality of Health Care for Vulnerable 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, a new study by the RAND Corporation and UCLA reports.

Researchers said the study shows that 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.

The study—published in the Nov. 4 edition of the Annals of Internal Medicine—also shows that older patients and their families need to become better informed about geriatric health care to ensure that older patients are getting proper care. Titled “Quality of Medical Care Provided to Vulnerable Community Dwelling Older Patients,” the study evaluated health care using quality indicators developed by the Assessing the Care of Vulnerable Elders (ACOVE) project.

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.

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. Educating consumers about the right questions to ask of their medical providers is a powerful first step in increasing the quality of care for our nation's vulnerable elderly.”

The research announced today 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.

Wenger said 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.

“Older patients are a minority in most primary care practices so many of the illnesses of aging are seen less frequently than conditions such as heart disease and diabetes.”

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 they must take to properly assess and treat geriatric illnesses, Wenger said.

The study found differences in how well care was delivered at each step along the way. Preventive care met standards 43 percent of the time, necessary steps to make a diagnosis occurred 46 percent of the time, care to treat an illness met standards 81 percent of the time, and appropriate follow-up occurred 63 percent of the time.

Wenger and his colleagues 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.

But the quality of health care dropped off sharply for age-related illnesses that can profoundly affect the lives of older patients by threatening their independence and otherwise diminishing the quality of their lives by leaving them unable to care for themselves and carry out daily activities, researchers found.

In addition to Wenger and Shekelle, other authors of the study are: Dr. David H. Solomon and Dr. Catherine H. MacLean of RAND and UCLA; Carol P. Roth, Caren J. Kamberg, Elizabeth M. Sloss, Rachel Louie and John Adams, all of RAND; Dr. Laurence Z. Rubenstein of the Greater Los Angeles Veterans Affairs Healthcare System; Dr. Roy T. Young and Dr. John T. Chang, both of UCLA; Dr. Debra Saliba of RAND and the Greater Los Angeles Veterans Affairs Healthcare System; Patricia J. Venus of the United Healthcare Center for Health Policy and Evaluation; and John F. Schnelle of the Los Angeles Jewish Home for the Aging and the Borun Center for Gerontological Research.

Researchers based the new study on their analysis of the medical records of 420 vulnerable older patients enrolled in two managed care organizations—one located in the Southwest and another in the Northeast. Researchers reviewed records from both inpatient and outpatient care received from July 1998 to July 1999.

The quality of medical care given to older patients was judged by assessing more than 200 indicators of quality devised for 22 different conditions.

The seniors studied lived in the community, rather than in nursing homes, but suffered underlying health problems that made them vulnerable to functional decline or death. Researchers said they noted no difference between the care given to people enrolled in the two medical plans.

RAND Health is the nation's largest independent health policy research organization, with a broad research portfolio that focuses on health care quality, costs, and delivery, among other topics.