Quality healthcare equals survival, at least for senior citizens at risk for declining health, according to a report in the current issue of the Annals of Internal Medicine.
While the study could not prove that lower quality of care causes death, it does suggest that higher quality of care increases survival rates for this population -- news that Neil Wenger, M.D., a co-author of the report, said is both historic and vitally important.
"This is the first study that looked at older patients and asked, 'Do patients who get better care do better?' " said Wenger, a University of California Los Angeles professor of medicine and researcher at Rand Health, a healthcare policy research division of the Rand Corp. think tank. "It pretty decisively says 'Yes.' This screams at me to make sure they get high-quality care."
The study, which was part of a joint project between Rand and drugmaker Pfizer called "Assessing the Care of Vulnerable Elders," looked at managed-care records for 372 patients age 65 and older and who were considered at high risk for worsening health within two years. The study was conducted between July 1, 1998, and July 31, 1999. A check of their mortality rates found that more patients who received a higher percentage of the recommended care for their conditions were alive after three years compared with those who received a lower percentage.
The patients' average age was 81, and the researchers identified 236 acts of medical care, or quality indicators, for the 22 different clinical areas for which the patients in the sample required medical attention.
For the various combinations of comorbid conditions these patients had, the report said there was evidence suggesting that each one should have received between eight to 54 different preventive, diagnostic, treatment or follow-up acts or quality indicators, with an average of 21 per patient.
On average, the researchers found the patients received 53% of the recommended care for their conditions. The researchers then split the sample in half and found the top half, which on average received about 62% of the recommended care, had an 18% mortality rate after three years, compared with a 28% mortality rate for the lower half, which on average received 44% of the recommended care.
"This suggests that poor quality of care translates into worse patient outcomes," Wenger said. "Quality is associated with survival."
Wenger, however, noted that survival might not be the most important outcome for older patients who place a higher value on quality of life or ability to function or live at home rather than in an institution.
Eighty-six patients, or 23%, died within three years, with the leading causes of death being cardiovascular disease (27%), respiratory disease (21%) and cancer (12%).
Patients in the top half received from 52% to 88% of the recommended care, while those at the bottom half received between 22% and 52%.
"It really is a problem because doctors will get all sorts of feedback on whether they're using the right drug, but very little feedback on preventive practices," Wenger said, who added that the response he and his colleagues have received regarding this study has been positive.
"Most of the feedback we've received is that this is a real wake-up call -- the care that we provide is not meeting the needs of our older patients," he said.
Dvid Schulke, executive vice president of the American Health Quality Association, which represents healthcare quality improvement organizations, said the study added to a small but growing body of evidence that showed how using process measures was an effective way of predicting mortality and evaluating quality. He further explained that the use of quality indicators was a "process measure," but that these indicators themselves should not be considered measures.
"There are too many 'confounders' in the way, so indicators don't tell you about the health of a patient, but they help you manage the care of the patient," Schulke said.
He said that without the use of information technology to help sort things out, medical records for older patients become nothing more than "just a stack of paper with a clip."
"Coordination of care becomes exponentially more difficult with each specialist added," Schulke said. "This shows why you need a prayer to get it done without IT."
The study took into account the health of the patients, and Wenger said it didn't appear that there was a difference in quality of care received by the sicker patients. Although it wasn't found in the study, Wenger said he has heard anecdotally that quality goes down for some sick patients who see multiple specialists because physicians may skip certain tests, treatments or procedures, assuming these are already being performed by another specialist on the patient's healthcare team.