Measuring Care for Vulnerable Older People ACOVE Measures

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Measuring Care forVulnerable Older PeopleACOVE
Measures

• Neil S. Wenger, MD, MPH
• UCLA Department of Medicine
• Maine Medical Center Annual Geriatrics Day
• April 1, 2009

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Case

• A 79 year old woman visits a new physician to
  establish primary care
• HTN, diabetes, COPD, osteoarthritis and
  osteoporosis
• Caring for her husband with mild/mod dementia
• Daughter drives her to appointments
• Tight household budget
• Deferential but only moderately adherent to
  recommendations
• Managed Medicaid insurance

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Why Measure the Quality of Carefor Older People?

• Use a lot of care
• Complex medical needs
• Vulnerable
• Cost

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By 2030

• There will be 71 million older Americans
• accounting for 20 of the U.S. population
• The nations health care spending is projected
• to increase by 25 due to this demographic shift
• -www.cdc.gov/aging

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Older people have more office visits
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.and hospitalizations
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Older people are at greater risk of adverse
effects of medical care
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and adverse events in the hospital
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Little Quality Evaluation Dedicated to the Needs
of Older Patients

• Limited information available on where older
  people can get care dedicated to their needs
• Limited pressure on the system to provide high
  quality geriatric care

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Limited In-depth Evaluation ofMedical Care for
Older Persons
Aspirin for AMI 84
Beta-blocker for AMI 78
Smoking counseling after AMI 38
EF evaluation during HF admit 71
Warfarin for atrial fibrillation 57
Flu immunization 71
Pneumococcal immunization 64
HgbA1c annually for DM 70
Eye exam in 2 years for DM 74
National data from 2000-01 from Jencks S, et al.
JAMA 2003289305-12.
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National Report Card on Healthy Aging
Mammogram past 2 years 75
Flu vaccine last year 68
Pneumonia vaccine 65
Colorectal cancer screening 63
Cholesterol check past 5 years 90
5 care processes among the 15 measures from the
CDC National Report Card on Healthy Aging. CDC
and Merck Co Foundation. State of Aging and
Health in America 2007.
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NCQA, NQF

• Few measures aimed at conditions particular to
  older people
• Unclear applicability to older patients of the
  measures for common medical conditions

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CMS Surgical Care Improvement Project(SCIP)
process measures

• Prophylactic preoperative antibiotic selection
  and timing
• Postoperative glucose control for cardiac surgery
  patients
• Preoperative hair removal
• Beta-blocker perioperatively for patients with
  CAD
• Venous thromboembolism prophylaxis
• Ventilator management
• Early postoperative wound infection diagnosis
• Mortality and readmission within 30 days of
  surgery

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National Measures of the Quality of CareCMS
PQRI Quality Indicators

• Diabetes HgbA1c, LDL, BP, renal and ophtho
  screening
• Heart failure ACEI, ß-blocker
• CAD antiplatelet, ß-blocker
• CVA DVT prophylaxis, tPA, antiplatelet, anticoag
  a fib, dysphagia screen, rehab
• Peri-op ß-blocker for CABG, abx, DVT
  prophylaxis,
• GERD assessing sx if on PPI
• Pneumonia vitals, O2 sat, cog, Rx
• OP screen, Rx, counsel vit D, Ca
• Ophtho glaucoma, MD, diabetes
• ER ASA ß-blocker for MI, ECG for CP or syncope

• COPD spirometry, therapy
• Asthma assessment, therapy
• MDS, Myeloma, CLL
• Breast, colon and prostate CA
• ESRD access, care plan, flu vaccine, adequacy
• Hepatitis C 8
• RA DMARD
• OA pain and function eval
• Depression DSM IV sx, suicide risk,
  antidepressant use
• Flu, pneumonia vaccine
• Mammogram
• CRC screening
• CKD labs, BP, ACEI

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National Measures of the Quality of CareCMS
PQRI Quality Indicators

• Medication reconciliation post-hospital D/C
  0.9
• Advance care plan 1.1
• Urinary incontinence
• Screening 0.5
• Characterization 2.4
• plan of care 2.5
• Screening for fall risk 1.4

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• To what degree do these measures give us
  information about the quality of care provided,
  as opposed to clinically appropriate deviations
  from ideal practice?
• Adapted from McMahon et al. Am J Man Care
  200713233-6.

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What would helpful care measurementlook like for
ill older patients?

• Conditions most important to older patients
• Comprehensive
• Accounts for offers of care, patient refusals
• Responsive to care for multiple conditions
• Accounts for preferences, health states

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Interventions to Maintain Independence
Hospital Admission Nursing Home Admission Death
Geri assess -all older people 0.98 (0.92 to 1.03) 0.86 (0.83 to 0.90) 1.00 (0.98 to 1.03)
Geriatric assess -frail older pop 090 (084 to 098) 101 (083 to 123) 103 (089 to 119)
Post-discharge care 0.95 (0.90 to 0.99) 0.77 (0.64 to 0.91) 0.97 (0.89 to 1.05)
Falls interventions 0.84 (0.61 to 1.16) 1.26 (0.70 to 2.27) 0.79 (0.66 to 0.96)
-Beswick AD, et al. Complex interventions to
improve physical function and maintain
independent living in elderly people. Lancet.
2008371(9614)725-35.
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Technical Aspects of Quality of Care Measurement
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Why Measure Quality of Care?

• To identify care that should be emulated
• To illustrate deficits that must be improved
• To identify predictors of quality care outcomes

Recommended care
Quality Gap
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Conceptual Framework of Quality of Care

• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-centered
• Institute of Medicine

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Donabedians Definition of Quality of Care

• Quality is that which is expected to maximize an
  inclusive measure of patient welfare, after one
  has taken account of the balance of expected
  gains and losses that attend the process of care
  in all its parts.
• Donabedian A. Promoting quality through
  evaluating the process of patient care. Med
  Care. 19686181-202.

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How is quality of care assessed?

• Donabedian Quality Model

Structure Material Resources Operational
Characteristics Organizational Characteristics
Process Clinical Care Policy and
Procedure Adherence to standards
Outcome Health status of patients Clinical
measures
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Problems with Outcome Measurement

• Important outcomes are rare events
• Outcomes are affected by patient characteristics
  more than by providers
• Case-mix adjustment is difficult
• Long lag may exist between care provided and
  beneficial outcomes

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Intermediate Outcomes

• Examples blood pressure control, HgbA1c
• More immediately influenced by clinical
  interventions
• More common than health outcomes
• Affected by both medical interventions and
  patient factors

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Process Measurement

• Sometimes easier to measure
• Timing
• Measurement source
• Differences in process are easier to interpret
  than differences in outcomes
• Providers more likely to be accountable for
  process of care
• Translate into quality improvement

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Technical Aspects ofQuality of Care Measurement

• Construction of process-of-care quality measures
• Case identification
• Data sources for quality measurement
• Testing the process outcome link
• Outcome measurement and risk adjustment

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What is Performance Measurement?

• Health care performance measurement is the
  process of using a tool based on research
  (performance measure) to evaluate a health plan
  or program, hospital, or health care practitioner
• Performance implies that the responsible health
  care providing entity can be identified, held
  accountable, and has control over the aspect of
  care being evaluated.

-Understanding Performance Measurement
www/ahcpr.gov/chtoolbx
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Characteristics of Quality Indicators

• Aim of the Quality Indicator
• Research
• Quality improvement
• Accountability
• Level of Measurement
• Healthcare system
• Health plan
• Emergency room / Hospital
• Medical / Physician group
• Physician

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Guidelines v. Quality Indicators

• Guidelines Tools to help set individualized
  goals by providers and patients should not be
  considered a maximum or minimum level of care.
• Quality Indicator Measurement tool that
  specifies patient eligibility and care (or
  outcome) that if not met nearly always indicates
  that the patient received inadequate quality care.

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Constructing Process of Care QIs

• Clinical evidence and clinical agreement that the
  process - outcome link is strong enough that not
  providing the care process is bad care
• Clearly specified eligible patient (If)
• Clearly specified care process (Then)
• Timing
• Responsible party / venue
• Specified exclusions
• Contraindications
• Refusals
• Inconsistent with level of aggressiveness / goals

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Example of Quality of Care Indicator Falls

• IF a patient reports 2 or more falls in the past
  year, or 1 fall with injury requiring medical
  care,
• THEN a fall evaluation should be performed,
  including history and examination.
• BECAUSE
• Some reasons for falling can be treated
• RCTs show that treatment reduces the risk for
  future falls

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Accounting for Preferencesand Clinical Condition

• Factor affecting Measurement
• Specific refusal of the care process
• Overarching care goals
• no surgery
• no hospitalization
• Patients with advanced dementia or poor prognosis

• Example
• Bisphosphonate therapy for osteoporotic fracture
• Colon cancer screening
• Intermediate-term prevention or burdensome
  treatment

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Quality Indicators aimed atVulnerable Older
Adults ACOVE measures
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Development of Quality Indicators

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Medical ConditionsBPHBreast cancerColon
cancerCOPDDepressionDiabetesHearing
impairment Heart failureHypertensionIschemic
heart diseaseOsteoarthritisOsteoporosisSleep
disordersStroke (atrial fibrillation)Vision
impairment
ACOVE Measures
Geriatric Conditions Dementia /
Delirium End-of-life and palliative careFalls
and mobility disordersMalnutrition Pressure
ulcersUrinary incontinence Cross-cutting Care
Processes Coordination of care Hospital
care Medication use Pain management Prevention /
Screening
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Concepts Incorporated

• Process prior to development of condition
• Caring and caregivers
• Detect unrecognized conditions
• Functional status
• Avoid inappropriate care
• Coordination of care
• Avoid gaming
• Account for contraindications, preferences,
  prognosis

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Quality Indicators Span the Range of Care
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Indicators by Care Processes
Intervention Indicators Assistive device
8 2 Counseling 50 13 Diet 5 1 Exercise 10 3 H
istory 65 17 Information continuity 40 10 Labora
tory test 26 7 Medication 97 25 Nursing
procedure 5 1 Physical exam 29 7 Procedure,
complex 25 6 Referral 14 4 Surgery 8 2 Test,
simple 9 2 100
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Applying the ACOVEQuality of Care Indicators
ACOVE-1

• Two senior managed care plans
• Random selection of enrollees age gt65 in
  community
• Telephone interview to identify vulnerable
  elders
• Medical record review
• outpatient, inpatient, mental health, nursing
  home, home care
• 13 months
• Quality-of-care interview

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Characteristics of ACOVE-1 Study Sample (N372)
Female () 64.8 Mean age, years (range) 80.6
(66-98) Self-rated health (mean 5poor,
1excellent) 2.6 ADL disability (mean)
0.5 IADL disability (mean) 1.2 Cognitive
score (mean, 28-point scale) 16.3
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Vulnerable Elders Receive About 1/2 of
Recommended Care
of recommended care received
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Why do we need to measure Geriatric Care?
Medical Conditions
Geriatric Conditions
31 passed
52 passed


-Ann Intern Med 2003139740-7.
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Example of Care Given to Vulnerable
ElderExamination After a Fall
6 Blood pressure
25 Vision
7 Gait and balance
28 Neurological exam
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Example of Care Given to Vulnerable Elder
Approach to Urinary Incontinence
50 document some history
22 dedicated exam
38 urine test
13 behavioral treatment suggested
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Classifying Care Processes by Burdens/Goals
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of Excluded QIs by Burdens/Goals
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Percentage of Excluded QIs forAdvanced Dementia
and Poor Prognosis
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Relationship between Quality and Survival
3 year survival for 10 equal interval of quality
score
1
Survival
r0.77
0
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88
Quality Score
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Quality is Unrelated to Vulnerability

mean quality for a given VES score
90
Quality Score ()
80
70
60
50
40
30
20
3
4
5
6
7
8
9
10
Vulnerable Elders Survey-13 Score
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Technical Quality of Care Unrelated to Patient
Care Ratings
-Chang J, et al. Ann Intern Med. 2006144665-72.
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Revisit the Case

• 79 year old woman establishing primary care
• HTN, diabetes, COPD, osteoarthritis and
  osteoporosis
• Caring for her husband with mild/mod dementia
• Daughter drives her to appointments
• Tight household budget
• Deferential but only moderately adherent to
  recommendations
• Managed Medicaid insurance

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What Care would Guidelines Suggest?

• Boyd et al. analyzed clinical guidelines
  available in 2005 for a simple and inexpensive
  treatment plan
• 12 medications 19 doses taken at 5 different
  times of day
• 10 patient tasks, some complex
• 18 physician tasks
• Multiple potential interactions
• gt400 medication monthly costs
• JAMA 2005294716-24.

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Inadequate Time for Recommended Care?

• Minimum physician time required to deliver
  guideline directed care for 10 chronic diseases
  to a panel of 2,500 primary care patients with an
  age-sex distribution and chronic disease
  prevalence similar to general population
• If the 10 conditions were stable 3.5 hours/day.
• If the 10 conditions were unstable, 10.6
  hours/day.
• Ostbye T, et al. Is there time for management of
  patients with chronic diseases in primary care?
  Ann Fam Med. 20053209-14.

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Quality of Care Increases as a Patients Chronic
Conditions Increase
VA
Quality score()
CQI
ACOVE
Number of chronic conditions
-Higashi T, et al. N Engl J Med.
20073562496-504.
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Effects of Adjusting for Patient Characteristics
and Health Care Use
Percentage-point increase in quality score for
each additional condition
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ACOVE Indicators by Data Source
-MacLean CH, et al. Med Care. 200644141-8.
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Summary Performance ScoresAll QIs
83
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152 36
of QIs
7,773 1,981
of observations
Data Source
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Summary Performance ScoresIdentical QIs
86
84
33 33
of QIs
of observations
1,500 1,500
Data Source
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Conclusions

• Quality of care evaluation is feasible .But
  not yet entirely practical
• To measure quality for our older patients
• Measure at the appropriate level
• Aim at important aspects of care
• Account for refusals, preferences and health
  states
• Advance measurement that
• Includes geriatric-oriented measures
• Data elements in electronic health records

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