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IMPROVING PATIENT CARE

Improving Patient Care is a special section within Annals supported in part by the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ). The opinions expressed in this article are those of the authors and do not represent the position or endorsement of AHRQ or HHS.

Quality of Care Is Associated with Survival in Vulnerable Older Patients

Takahiro Higashi, MD, PhD; Paul G. Shekelle, MD, PhD; John L. Adams, PhD; Caren J. Kamberg, MSPH; Carol P. Roth, RN, MPH; David H. Solomon, MD; David B. Reuben, MD; Lillian Chiang, MD; Catherine H. MacLean, MD, PhD; John T. Chang, MD, MPH; Roy T. Young, MD; Debra M. Saliba, MD, MPH; and Neil S. Wenger, MD, MPH

16 August 2005 | Volume 143 Issue 4 | Pages 274-281

Background: Although assessment of the quality of medical care often relies on measures of process of care, the linkage between performance of these process measures during usual clinical care and subsequent patient outcomes is unclear.

Objective: To examine the link between the quality of care that patients received and their survival.

Design: Observational cohort study.

Setting: Two managed care organizations.

Patients: Community-dwelling high-risk patients 65 years of age or older who were continuously enrolled in the managed care organizations from 1 July 1998 to 31 July 1999.

Measurements: Quality of care received by patients (as measured by a set of quality indicators covering 22 clinical conditions) and their survival over the following 3 years.

Results: The 372 vulnerable older patients were eligible for a mean of 21 quality indicators (range, 8 to 54) and received, on average, 53% of the care processes prescribed in quality indicators (range, 27% to 88%). Eighty-six (23%) persons died during the 3-year follow-up. There was a graded positive relationship between quality score and 3-year survival. After adjustment for sex, health status, and health service use, quality score was not associated with mortality for the first 500 days, but a higher quality score was associated with lower mortality after 500 days (hazard ratio, 0.64 [95% CI, 0.49 to 0.84] for a 10% higher quality score).

Limitations: The observational design limits causal inference regarding the effect of quality of care on survival.

Conclusions: Better performance on process quality measures is strongly associated with better survival among community-dwelling vulnerable older adults.

Editors' Notes Context Quality-of-care evaluation often focuses on how often patients receive certain tests or treatments. Theoretically, the content of care should predict patient survival, but the evidence is inconclusive. Contribution This study used 207 criteria to assess good care in 372 vulnerable elderly patients. When care did not meet these standards, patients were more likely to die during the 3 years of follow-up. Implications In vulnerable older patients, the content of care is associated with mortality. This finding supports the use of process measures in the evaluation of quality of care and shows that good care may prolong life. –The Editors

 

Author and Article Information

From RAND Health, Santa Monica, California, and Washington, DC, and the University of California, Los Angeles, and the Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California.

Acknowledgments: The authors thank Robert Brook, MD, ScD, for inspiration and guidance; Robin P. Hertz, PhD, senior director of outcomes research and population studies at Pfizer Inc, for providing valuable support; and Patricia Smith and Victor Gonzalez for their technical assistance.

Grant Support: Supported by a contract from Pfizer Inc. Dr. Higashi is supported by a St. Luke's Life Science Institute Fellowship Award. Dr. Shekelle was a Senior Research Associate of the Veterans Affairs Health Services Research & Development Service. Dr. Chiang is supported by a Bureau of Health Professionals Geriatrics Research Faculty Training Program. Drs. MacLean and Saliba are Research Associates of the Veterans Affairs Health Services Research & Development Service. Dr. Chang is supported by a National Research Service Award (PE-19001) and the University of California, Los Angeles, Specialty Training and Advanced Research (STAR) Program.

Potential Financial Conflicts of Interest: Stock ownership or options (other than mutual funds): R.T. Young (Pfizer Inc).

Requests for Single Reprints: Neil S. Wenger, MD, MPH, RAND, 1700 Main Street, Santa Monica, CA 90407.

Current Author Addresses: Dr. Higashi: Department of Epidemiology and Healthcare Research, Kyoto University, Yoshida-konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan.

Dr. Chang: Division of General Internal Medicine, University of California, Los Angeles, 911 Broxton Plaza, Los Angeles, CA 90095-1736.

Drs. Shekelle, MacLean, and Saliba: Greater Los Angeles Veterans Affairs Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA 90073.

Drs. Solomon, Adams, and Wenger and Ms. Roth: RAND, 1700 Main Street, M-26, Santa Monica, CA 90407-2138.

Ms. Kamberg: RAND, 1200 South Hayes Street, Arlington, VA 22202.

Dr. Young: Division of General Internal Medicine, University of California, Los Angeles, 200 Medical Plaza, Los Angeles, CA 90095-1736.

Drs. Reuben and Chiang: Division of Geriatrics, University of California, Los Angeles, 200 Medical Plaza, Los Angeles, CA 90095-1736.

Related articles in Annals:

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Annals 2005 143: 305-306. [Full Text]  

Summaries for Patients
Association of Quality of Care with Survival of Elderly Managed Care Patients

Annals 2005 143: I-33. [Full Text]  

Letters
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Stephanie L. Garrett, James G. O'Brien, AND Toni P. Miles

Annals 2006 144: 219. [Full Text]  

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