Application of assessing care of vulnerable elders-3 quality indicators to patients with advanced dementia and poor prognosis.
OBJECTIVE
To use a formal decision-making strategy to reach clinically appropriate, internally consistent decisions on the application of quality indicators (QIs) to vulnerable elders (VEs) with advanced dementia (AD) or poor prognosis (PP).


METHODS
Using a conceptual model that classifies QIs principally by aim and burden of the care process, 12 clinical experts rated whether each Assessing Care of Vulnerable Elders-3 (ACOVE-3) QI should be applied in evaluating quality of care for older persons with AD or PP. QI exclusions were assessed for each of the 26 conditions and by whether these conditions were mainly medical (e.g., diabetes mellitus), geriatric (e.g., falls), or crosscutting processes of care (e.g., pain management). QI exclusions were also identified for older persons who decided against hospitalization or surgery.


RESULTS
Of 392 ACOVE-3 QIs, 140 (36%) were excluded for patients with AD and 135 (34%) for patients with PP; 57% of QIs focusing on medical conditions were excluded from patients with AD and 53% from patients with PP, whereas only 20% of QIs for geriatric conditions were excluded from AD and 15% from PP. All QIs with care processes judged to carry a heavy burden were excluded; 86% of moderate-burden QIs were excluded from AD and 92% from PP. All QIs aimed at long-term goals were excluded; 83% of intermediate-term goal QIs were excluded from AD and 98% from PP. Individuals holding a preference to forgo hospitalization or surgery would be excluded from 7% of potentially applicable QIs.


CONCLUSIONS
Measurement of quality of care for VEs with AD, PP, and less-aggressive care preferences should include only a subset of the ACOVE-3 QIs, largely those whose burden is light and whose goal is continuity or short-term improvement or prevention.
Wenger
Neil S
NS
RAND Health, Santa Monica, CA 90407-2138, USA. nwenger@mednet.ucla.edu
Solomon
David H
DH
Amin
Alpesh
A
Besdine
Richard K
RK
Blazer
Dan G
DG
Cohen
Harvey
H
Fulmer
Terry
T
Ganz
Patricia A
PA
Grunwald
Mark
M
Hall
William J
WJ
Katz
Paul R
PR
Kitzman
Dalane W
DW
Leipzig
Rosanne M
RM
Rosenthal
Ronnie A
RA
D000368:Aged; D017028:Caregivers / Q000523:psychology; D003266:Continuity of Patient Care; D017281:Cost of Illness; D003657:Decision Making; D003704:Dementia / Q000150:complications*; D019317:Evidence-Based Medicine; D016330:Frail Elderly; D015577:Geriatric Assessment; D006801:Humans; D017064:Process Assessment, Health Care / Q000379:methods*; D011379:Prognosis; D019984:Quality Indicators, Health Care; D012720:Severity of Illness Index