Poor Care for Elderly Linked to Early Death

Treatment that meets recommended guidelines pays off, study finds

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By Karen Pallarito
HealthDay Reporter

MONDAY, Aug. 15, 2005 (HealthDay News) -- Older patients in declining health who receive fewer recommended tests or treatments for the conditions they suffer from are at greater risk of dying after three years than their peers who get higher quality care, a new study finds.

The researchers say their study is the first to show that broad-based "process of care" measures can be used to predict patient survival among vulnerable elderly individuals.

Put simply, when doctors provide care that's consistent with recommended guidelines -- whether it's assessing the functional status of a dementia patient, checking the blood sugar of someone with diabetes, or administering a pneumococcal vaccine to ward off pneumonia -- patients do markedly better.

"Better quality meant better outcome," said Dr. Paul G. Shekelle, a consultant in health sciences at RAND Health and one of the study co-authors.

The report appears in the Aug. 16 issue of the Annals of Internal Medicine.

Among patients who received more recommended care, 18 percent died after three years compared with 28 percent of those who received less care, the study found.

"We were expecting to see a relationship," said Shekelle, who is also a physician at the Greater Los Angeles VA Healthcare System, "but we were surprised at the strength of it."

Dr. Harlan M. Krumholz, a professor of medicine, epidemiology and public health at the Yale University School of Medicine, said, "The reason an article like this is important is because, at a time when we're spending more and more money on health care and being drawn to fancier innovations, studies like this tell us we're not even doing the basics."

The new results come from an ongoing project called Assessing the Care of Vulnerable Elders (ACOVE), a collaborate initiative of Rand Health and Pfizer Inc. Earlier findings showed that older patients at risk of declining health receive only a portion of recommended care and receive recommended medications only half of the time.

The latest phase of the study involved 372 vulnerable patients, ages 65 and older, in two managed care plans. All of them lived in the community but were at high risk for death or decline over the next two years based on age, self-reported health and function.

Lead author Dr. Takahiro Higashi, now of Kyoto University School of Medicine in Japan, and his colleagues examined the quality of care the patients received over a 13-month period, from July 1, 1998, to July 31, 1999. Then they followed patients for three years to see whether there was any relationship between the quality of care delivered and their survival.

In fact, the death rate was lower among patients who received better quality care. And when patients were grouped into 10 intervals based on their quality score, the authors observed a "dose response" relationship between quality and outcome. In other words, patient survival rose with each level of higher quality.

There's another possible explanation for the observed quality-survival link. It could be that physicians simply provide less care to patients in declining health because they assume those people are going to die anyway. But the authors are reasonably certain that's not the case. When they examined the factors that doctors would use to predict a person's decline, including age and the number of health problems a patient suffers from, they found no relationship with quality.

Still, skeptics question whether measuring the things that doctors do to keep patients healthy means that people are better off. This study is a "first big step" toward providing an answer, Shekelle said, because the people whose care wasn't so good had poor outcomes.

"What's missing is the next step," he added. "If you intervene to make the lousy care better, would you make it so they don't die as fast?"

In an editorial in the same issue of the journal, Dr. Sankey V. Williams of the University of Pennsylvania said the findings "remind us that if vulnerable patients want the best we have to offer, we should do everything we can for them, not just what seems practical."

More information

For more on health care for the elderly, visit the Agency for Healthcare Research and Quality.

SOURCES: Paul G. Shekelle, M.D., consultant, health sciences, RAND Health, Santa Monica, Calif., and physician, Greater Los Angeles VA Healthcare System, Los Angeles; Harlan M. Krumholz, M.D., professor of medicine, epidemiology and public health, Yale University School of Medicine, New Haven, Conn.; Aug. 16, 2005, Annals of Internal Medicine

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