Measuring Care for Vulnerable Older People ACOVE Measures

1. Measuring Care forVulnerable Older PeopleACOVE Measures Neil S. Wenger, MD, MPH UCLA Department of Medicine Maine Medical Center Annual Geriatrics Day April 1, 2009

2. 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

3. Why Measure the Quality of Carefor Older People? • Use a lot of care • Complex medical needs • Vulnerable • Cost

4. By 2030 There will be 71 million older Americans accounting for 20% of the U.S. population The nation’s health care spending is projected to increase by 25% due to this demographic shift -www.cdc.gov/aging

5. Older people have more office visits

6. ….and hospitalizations

7. Older people are at greater risk of adverse effects of medical care

8. …and adverse events in the hospital

9. 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

10. Limited In-depth Evaluation ofMedical Care for Older Persons National data from 2000-01 from Jencks S, et al. JAMA 2003;289:305-12.

11. National Report Card on Healthy Aging 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.

12. NCQA, NQF • Few measures aimed at conditions particular to older people • Unclear applicability to older patients of the measures for common medical conditions

13. 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

14. Diabetes HgbA1c, LDL, BP, renal and ophtho screening Heart failure ACEI, β-blocker CAD antiplatelet, β-blocker CVA: DVT prophylaxis, tPA, antiplatelet, anticoag a fib, dysphagia screen, rehab Peri-op: β-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 & β-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 National Measures of the Quality of Care:CMS PQRI Quality Indicators

15. National Measures of the Quality of Care:CMS 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%

16. 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 2007;13:233-6.

17. 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

18. Interventions to Maintain Independence -Beswick AD, et al. Complex interventions to improve physical function and maintain independent living in elderly people. Lancet. 2008;371(9614):725-35.

19. Technical Aspects of Quality of Care Measurement

20. Actual Care 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

21. Conceptual Framework of Quality of Care • Safe • Timely • Effective • Efficient • Equitable • Patient-centered • Institute of Medicine

22. Donabedian’s 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. 1968;6:181-202.

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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.

31. 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

32. 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, THENa 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 32

33. 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 Accounting for Preferencesand Clinical Condition

34. Quality Indicators aimed atVulnerable Older Adults“ACOVE” measures

35. Content experts, systematic literature review, peer review 26 Conditions for quality improvement 484 Proposed indicators 392 Accepted indicators Clinical Oversight Committee Expertpanels Development of Quality Indicators

36. ACOVE Measures Medical ConditionsBPHBreast cancerColon cancerCOPDDepressionDiabetesHearing impairment Heart failureHypertensionIschemic heart diseaseOsteoarthritisOsteoporosisSleep disordersStroke (atrial fibrillation)Vision impairment 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

37. 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

38. Number of Indicators Prevention/screening 121 Diagnosis 80 Treatment 137 Follow-up/continuity 54 392 Quality Indicators Span the Range of Care

39. Indicators by Care Processes InterventionIndicators% Assistive device 8 2 Counseling 50 13 Diet 5 1 Exercise 10 3 History 65 17 Information continuity 40 10 Laboratory 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

40. Applying the ACOVEQuality of Care Indicators: ACOVE-1 • Two senior managed care plans • Random selection of enrollees age >65 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

41. Characteristics of ACOVE-1 Study Sample (N=372) Female (%) 64.8% Mean age, years (range) 80.6 (66-98) Self-rated health (mean 5=poor, 1=excellent) 2.6 ADL disability (mean) 0.5 IADL disability (mean) 1.2 Cognitive score (mean, 28-point scale) 16.3

42. Vulnerable Elders Receive About 1/2 of Recommended Care % of recommended care received

43. Why do we need to measure “Geriatric Care”? Medical Conditions Geriatric Conditions 31% passed 52% passed -Ann Intern Med 2003;139:740-7.

44. Example of Care Given to Vulnerable Elder:Examination After a Fall 6% Blood pressure 25% Vision 7% Gait and balance 28% Neurological exam

45. 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

46. Classifying Care Processes by Burdens/Goals

47. % of Excluded QIs by Burdens/Goals

48. Percentage of Excluded QIs forAdvanced Dementia and Poor Prognosis

49. Relationship between Quality and Survival 3 year survival for 10 equal interval of quality score 1 Survival r=0.77 0 27% 88% Quality Score

50. 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